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THE  BREAST 

LESIONS  OF  THE 
FEMALE  BREAST 


JOSEPH  COLT  BLOOD  GOOD 

B.  SC,  M.  D.,  P.  A.  C.  S. 

Baltimore,  Md. 


Reprinted  from 

Binnie's  Regional  Surgery 

Vol.  I,  Section  23 


1917 


P.  Blakiston's  Son  &  Company 
1012  Walnut  Stbbbt,  Philadelphia 


THE  BREAST 

SECTION  XXIII 
LESIONS  OF  THE  FEMALE  BREAST 

By 
JOSEPH    COLT  BLOODGOOD,  B.  SC,   M.  D.,   F.   A.   C.   S. 

Baltimore,  Md. 

Attention  is  called  to  the  female  breast  by  swelling,  or  tumor, 
pain,  discharge  from  or  retraction  or  ulceration  of,  the  nipple;  some 
change  in  an  area  of  skin  over  the  breast,  or  the  palpation  of  some 
enlargement  of  the  glands  in  the  axilla. 

When  the  patient  seeks  advice  for  one  or  more  of  these  signs  and 
symptoms,  we  may  be  somewhat  influenced  and  helped  in  our  in- 
terpretation of  their  significance  by  the  following  additional  data :  age, 
duration  of  symptoms;  whether  the  symptoms  had  disappeared  to 
reappear — especially  tumor;  whether  the  woman  is  married  or  single, 
whether  pregnant  or  nursing  her  child,  the  number  of  children  and 
the  age  of  the  youngest;  whether  there  has  been  a  history  of  trauma 
or  mastitis;  whether  the  menstruation  is  normal,  changing,  or  the 
menopause  established.  The  existence  of  pelvic  irritating  lesions 
should  also  be  carefully  investigated. 

Breast  Lesions. — We  may  have  at  birth,  puberty  and  during 
pregnancy  a  diffuse  enlargement  of  both  breasts — a  condition  which 
can  always  be  recognized  clinically  and  should  never  be  confused 
with  a  malignant  tumor. 

Mastitis  as  a  rule  is  associated  with  lactation.  It  is  always  a 
diffuse  lesion,  never  encapsulated,  but  may  be  circumscribed.  We 
do  observe  mastitis  in  breasts  which  are  not  lactating.  Then  the 
mastitis  is  usually  tubercular. 

I  We  do  not  know  the  etiology  of  chronic  cystic  mastitis.  The 
affected  area  is  never  encapsulated  but  the  large  cysts  which  develop 
in  a  large  per  cent,  of  cases  are  individually  encapsulated.  The 
disease  may,  however,  appear  as  a  circumscribed  tumor. 

Cysts   of   the  breast  are  galactoceles   associated  with  lactation; 

557 
Copyright,  191 7,  by  P.  Blakiston's  Son  &  Co. 


558  REGIONAL    SURGERY 

pyogenic  and  tuberculous  abscesses;  cysts  in  chronic  cystic  mastitis; 
papillomatous  cysts,  benign  and  malignant;  and  the  true  cancerous 
and  sarcomatous  cyst. 

Encapsulated  tumors  are  always  benign.  They  are  the  cystic 
adenoma,  the  fibroadenoma  and  the  intracanalicular  myxoma.  These 
tumors,  however,  may  appear  as  circumscribed  areas  difi&cult  to 
differentiate  from  adenocarcinoma. 

Mahgnant  tumors  are  never  encapsulated,  although  they  may 
be  circumscribed.  The  types  of  malignant  tumors  are  the  adeno- 
carcinoma, the  scirrhous  and  medullary  carcinoma,  and  the  sarcoma. 

We  must  recollect  that  cancer  may  begin  in  the  breast  during 
pregnancy,  during  lactation,  and  at  any  period  of  life  after  twenty-five. 

Cancer  may  form  in  the  scar  residual  after  mastitis  in  which  the 
original  lump  had  remained  quiescent  for  from  lo  to  30  years. 

Tumors  may  remain  quiescent  in  the  breast  for  many  years.  When 
growth  suddenly  appears,  it  is  usually,  but  not  always,  associated 
with  malignant  change. 

To  increase  the  number  of  cures  of  cancer  of  the  breast,  we  must 
give  women  the  proper  information  which  will  influence  them  to  seek 
an  examination  the  moment  after  they  feel  a  lump. 

The  most  difficult  problem  falls  upon  the  surgeon — to  differentiate 
at  the  exploratory  incision  the  various  t>^es  of  breast  lesions  and  to 
decide  then;  whether  to  remove  the  lump,  the  breast,  or  to  perform 
the  complete  operation  for  sarcoma  or  carcinoma. 

Age. — ^Among  885  malignant  tumors  of  the  breast  thirty-five  or 
3.9  per  cent,  have  been  under  thirty  years  of  age  when  the  lump  was 
first  observed.  In  10  cases  the  age  of  onset  varied  from  15  to 
25  years.  In  six  cases  of  cancer  in  which  the  age  of  onset  was 
less  than  twenty-five,  the  tumors  had  been  observed  from  5  to  40 
years,  thus  offering  ample  time  for  removal  during  the  benign  stage. 

There  remains  but  one  positive  case  of  cancer  originating  in  a 
woman  younger  than  twenty-five.  This  patient  was  21  years  of  age 
and  had  observed  the  lump  but  a  few  months. 

Of  the  four  cases  of  sarcoma  in  which  the  patients  were  younger 
than  twenty-five  when  the  neoplasms  were  first  discovered,  in  two  the 
tumors  were  of  18  and  25  years'  duration  respectively.  The  remain- 
ing two  cases  are  from  outside  sources,  and  I  have  been  unable  to 
confirm  the  data. 

Therefore,  when  a  patient  with  a  lump  in  the  breast  is  twenty- 
five  or  less,   the  chances  of  a  malignant  tumor  are  remote.     After 


LESIONS    OF   THE    FEMALE  BREAST  559 

twenty-five  age  does  not  help  us,  because  cancer  has  been  observed 
from  twenty-six  to  seventy  and  over,  as  well  as  all  types  of  benign 
tumors. 

In  the  newborn  we  may  observe  enlargement  of  the  breast;  this  is 
usually,  if  not  always,  bilateral,  and  associated  with  a  discharge  milky 
in  character  {infantile  hypertrophy).  This  condition  recovers  spon- 
taneously. On  account  of  the  discharge  from  the  nipple,  efforts  to 
attain  and  maintain  cleanliness  should  be  great.  After  washing,  the 
nipple  should  be  protected  with  sterile  cotton.  Infections  have  taken 
place;  abscesses  and  erysipelas  have  secondarily  developed  with 
mortality.  My  one  observation  recovered,  and  now,  17  years  since, 
the  breast  has  normally  developed. 

During  childhood  diseases  of  the  breast  are  unusual  and  always 
benign.  Tumors  need  not  be  removed  unless  they  grow,  or  are  asso- 
ciated with  great  pain. 

At  puberty  benign  conditions  of  the  breast  are  often  first  observed. 
The  attitude  towards  all  lesions  at  this  period  should  be  conservative. 
Intense  pain,  rapidly  growing  tumor,  huge  enlargement  of  one  or  both 
breasts,  are  the  only  indications  for  operative  interference.  The 
object  of  such  an  operation  is  not  to  cure  any  hopeless  disease,  but  to 
check  and  remove  a  lesion  which,  if  left  alone,  would  destroy  the  breast, 
or  to  relieve  pain  by  the  removal  of  a  centrally  situated  tumor. 

Unilateral  Hypertrophy. — ^At,  or  shortly  after,  puberty  the  de- 
velopment of  one  breast  may  be  more  rapid  than  of  the  other.  In 
six  cases  of  my  own  observation  the  larger  breast  was  not  sufi&ciently 
large  to  excite  any  apprehension.  The  condition  was  really  not 
unilateral  hypertrophy,  but  unilateral  development.  In  these  six 
cases  after  a  time  the  more  slowly  developing  breast  caught  up  with  the 
other  and  symmetry  was  established.  In  one  case  the  h3rpertrophy 
of  the  left  breast  was  far  out  of  proportion  to  normal,  while  the  smaller 
breast  was  about  normal  for  a  girl  two  years  after  puberty.  In  this 
case,  with  the  hope  of  checking  the  hypertrophy,  a  plastic  resection  of 
a  quadrant  was  performed.  It  is  now  about  10  months  since  the 
operation,  and  there  has  been  no  further  enlargement.  We  know  from 
our  experience  with  operations  for  benign  tumors  of  the  breast  during 
and  after  puberty  that  there  is  no  harm  from  such  a  plastic  resection, 
but  we  have  no  evidence  as  yet  that  it  will  check  unilateral  hypertrophy. 

Diffuse  Bilateral  Virginal  Hypertrophy. — This  condition  has 
its  onset  at,  or  shortly  after,  puberty.  At  first  there  is  observed 
the  ordinary  puberty  h5rpertrophy.     Later  both  breasts   become   so 


56o 


REGIONAL   SURGERY 


much  larger  than  normal  that  interest  and  anxiety  are  excited.  In 
the  literature  the  cases  are  usually  observed  from  four  to  ten  years 
after  onset,  and  nothing  has  been  done  for  this  condition,  except  re- 
moval of  one  or  both  breasts.  Apparently  in  this  late  stage  nothing 
else  offers  any  relief.  If  these  cases  are  seen  in  the  beginning  of  the 
trouble,  menstrual  disorders  should  be  corrected,  sexual  disturbances 
controlled,  and  when  the  size  of  the  breast  has  gone  much  beyond 
normal,  plastic  resection  as  noted  above  might  be  attempted. 

Now  and  then  unilateral  hypertrophy  may  be  due  to  the  presence 
of  a  tumor  in  the  center  of  the  breast.     In  my  only  observation  in- 


FiG.  301. — Encapsulated  aberrant  fibroadenoma.     Tumor    larger    than    the     breast. 

Breast  to  the  median  side. 

Pathol.   No.   7135. — Operation  in   1906,  excision   of   tumor;   breast  saved.     Colored, 

female,  aged  19,  tumor  seven  months. 

tense  pain  was  the  indication  for  operation.  At  the  exploratory  in- 
cision previous  to  the  contemplated  plastic  resection,  the  central 
tumor  was  found  and  removed.  The  pain  was  relieved,  and  10  years 
later  this  breast  lactated  normally. 

At,  or  shortly  after,  puberty  tumors  in  the  region  of  the  breast 
may  develop,  grow  rapidly  and,  if  left  alone,  become  larger  than  the 
breast  itself  (Fig.  301 ) .  They  are  usually  incorrectly  diagnosed  sarcoma, 
and  the  young  patients  are  mutilated  for  Hfe  by  the  removal  of  a  nor- 
mal breast  with  a  benign  encapsulated  tumor.  These  are  aberrant  breast 
tumors,  and  will  be  discussed  again  under  fibroadenoma  (page  598). 

At  what  age  should  a  single  tumor  of  the  female  breast  be  removed? 


LESIONS  OF  THE  FEMALE  BREAST  561 

In  my  own  opinion,  if  the  patient  is  under  twenty,  the  tumor  may  be 
left  alone,  unless  it  exhibits  growth,  or  is  very  annoying  by  pain. 
Between  twenty  and  twenty-five  there  is  some  doubt  as  to  what  is 
best  to  do.  On  the  whole,  accumulated  experience  favors  operation. 
After  twenty-five  there  is  no  question — operate. 

In  many  of  the  single  and  multiple  tumors  in  girls  under  twenty- 
five  which  I  have  observed  during  the  past  25  years  the  tumors 
have  spontaneously  disappeared.  Young  girls,  if  possible,  "should 
not  be  subjected  during  puberty  to  operations  upon  the  breast. 
After  twenty  the  chances  of  spontaneous  disappearance  grow  less,  and 
as  the  tumor  certainly  should  be  removed,  if  it  does  not  disappear  in  a 
few  years,  why  wait?  There  is  no  danger  and  no  mutilation.  The 
removal  of  these  benign  tumors  protects  the  woman  from  growth 
of  this  tumor  which  may  take  place  during  a  subsequent  pregnancy 
or  lactation  at  a  time  when  an  operation,  even  for  a  benign  tumor, 
is  more  annoying  than  at  an  earlier  period.  There  is  also  no  doubt 
that  it  protects  the  woman  from  the  possible  development  of  a  cancer 
in  such  a  benign  tumor. 

In  women  after  25  years,  their  age  can  no  longer  be  used 
as  a  factor  either  against  operative  interference,  or  in  differential 
diagnosis.  Although  the  relative  proportion  of  benign  and  malignant 
diseases  of  the  breast  varies  with  the  age  of  the  patient,  it  is  not  suf- 
ficiently distinct  to  be  helpful.  If  a  surgeon  uses  age  in  his  differential 
diagnosis  after  twenty-five,  it  will  simply  increase  the  number  of  his 
mistakes. 

Duration  of  Tumor. — Theoretically,  our  patients  should  always 
see  us  at  once,  so  that  we  would  never  be  assisted  in  our  differential 
diagnosis  by  the  duration  of  the  disease.  When  the  woman  waits, 
always  at  her  own  risk,  the  surgeon  may  be  helped  by  the  long  duration 
of  the  disease  without  any  definite  change.  But  even  here,  there  are 
too  many  exceptions  to  the  rule,  to  allow  one  to  rely  much  on  the 
long  duration  of  the  disease.  Our  records  show  many  cases  of  cancer 
in  tumors  which  have  been  present  30  or  more  years.  We  know 
that  when  we  operated  the  tumors  were  cancer.  Our  records  may 
show  when  the  clinical  signs  of  cancer  first  developed,  but  we  have  no 
way  of  finding  out  when  or  why  the  malignant  change  took  place.  A 
tumor,  then,  of  many  years'^  duration  which  during  this  time  has 
shown  no  growth  and  is  quiescent  today,  may  begin  its  malignant 
change  tomorrow. 

36 


562  REGIONAL   SURGERY 

When  the  duration  of  the  symptoms  is  helpful  in  the  differential 
diagnosis,  I  will  mention  it  later  with  the  specific  lesion  under  discussion. 

The  relative  per  cent,  of  benign  and  malignant  lesions  of  the  breast 
in  our  1800  cases  has  changed  gradually  in  the  past  27  years,  and 
very  rapidly  in  the  past  three  years.  In  the  first  10  years  of  the 
observation  the  per  cent,  of  benign  lesions  was  32,  in  the  second  period 
of  10  years  it  was  41,  in  the  next  seven  years  it  was  54,  but  in  the  past 
three  years  59  as  compared  with  47  in  the  preceding  three  years.  This 
increasing  proportion  of  the  benign  lesions  of  the  breast  has  been  asso- 
ciated with  a  shortening  of  the  duration  of  the  disease,  and  the  latter 
has  been  due  to  the  education  of  the  profession  and  the  public.  Any 
clinic  reporting  today  a  larger  per  cent,  of  cancers  of  the  breast  sug- 
gests that  this  clinic  is  getting  late  cases. 

The  greatest  changes  which  we  have  observed  in  the  past  few 
years  in  diseases  of  the  breast  are  the  duration  of  the  disease,  and  its 
pathology. 

ETIOLOGICAL  FACTORS 

Trauma. — Many  breasts  are  bruised  and  after  the  contusion 
there  may  be  ecchymosis  and  even  palpable  induration.  All  of  these 
signs  may  disappear  and  nothing  develop  later.  There  are  apparently 
but  few  records  of  such  cases.  I  now  have  three  which  have  been 
followed  from  the  onset  of  the  injury.  In  the  oldest  case  it  is  three 
years  since  the  trauma.  This,  like  many  other  conditions  of  the 
breast,  may  be  frequent,  but  we  know  little  about  it,  because  those 
who  keep  records  are  not  consulted. 

On  the  other  hand,  the  number  of  breast  lesions  secondary  to 
trauma  is  relatively  small,  but  sufficiently  large  to  impress  one  that 
.  trauma  must  be  considered  an  etiological  factor.  All  the  cysts  of  the 
breast  which  I  have  seen  in  young  women  under  twenty-five  have 
followed  a  trauma.  In  sarcoma  of  the  breast  trauma  is  a  much  more 
frequent  etiological  factor  than  in  carcinoma.  Trauma  may  excite 
the  growth  of  a  pre-existing  tumor,  and  this  subsequent  growth  may 
be  either  benign  or  maHgnant.  The  history  of  a  trauma,  either 
positive  or  negative,  is  of  no  help  in  the  differential  diagnosis. 

Breasts,  however,  which  have  been  injured  should  be  carefully 
watched.  If  the  induration  which  immediately  followed  the  con- 
tusion does  not  disappear  in  a  few  weeks,  the  area  should  be  explored. 
If  an  area  of  induration  or  a  tumor  appears  some  days  or  weeks  after 


LESIONS    OF   THE    FEMALE  BREAST  563 

the  trauma,  in  cases  in  which  nothing  was  present  immediately  after 
the  trauma,  exploratory  operation  is  indicated  at  once. 

Infection. — In  the  absence  of  pregnancy  and  lactation,  the  breast 
is  especially  immune  to  metastatic  involvement  in  general  or  local 
infection,  yet  this  may  occur,  as  will  be  discussed  under  mastitis. 
When  we  have  a  local  infection  on  the  body  or  on  the  upper  extremity, 
the  breast  now  and  then  is  secondarily  involved.  When  the  patient 
gives  a  history  of  tuberculous  glands  of  the  neck  which  have  healed; 
when  scars  from  a  recent  suppuration  in  the  axilla  are  seen ;  when  sinuses 
are  found,  and  there  has  occurred  a  more  recent  enlargement  of  the 
breast,  the  chances  are  that  we  are  dealing  with  tuberculosis.  With- 
out such  a  history  such  a  breast  with  its  present  induration  and  re- 
tracted nipple  would  have  to  be  considered  the  seat  of  a  malignant 
lesion. 

The  history,  or  demonstration,  of  a  portal  of  infection  near  the 
infected  breast  may  now  and  then  urge  the  surgeon  to  explore  rather 
than  to  perform  the  complete  cancer  operation  for  a  breast  condition 
which  is  clinically  malignant.  But  these  are  unusual  conditions  and 
can  only  be  fully  considered  in  a  monograph  or  case  reports. 

Pregnancy. — If  a  lump  is  felt  in  the  breast  of  a  pregnant  woman 
and  the  patient  is  over  twenty-five,  it  should  be  explored  at  once; 
during  pregnancy  as  well  as  in  the  lactation,  cancer  disseminates  with 
greater  rapidity.  At  exploration,  a  benign  tumor  may  be  exposed 
(Fig.  307).  All  lesions  of  the  breast  during  pregnancy  are  unusual. 
Benign  and  malignant  tumors  are  about  equally  divided.  Among  the 
cancers  in  our  records  there  is  one  blood-cyst  and  no  sarcoma.  Among 
the  benign  lesions  tumors  predominate.  Mastitis  is  very  rare  and 
when  present  is  usually  tuberculous. 

When  a  woman  knows  that  she  had  the  lump  in  her  breast  before 
she  was  pregnant,  immediate  operation  is  not  so  essential,  but  it  is 
far  better  to  remove  the  lump  before  the  birth  of  the  child.  I  have 
usually  selected  the  period  between  the  third  and  the  fifth  month. 
The  tumor  should  be  removed,  because  during  lactation  it  is  more 
apt  to  give  trouble.  It  seems  safer  for  the  child  to  remove  the  breast 
tumor  during  pregnancy  than  during  nursing. 

Diffuse  Bilateral  Gravidity  Hypertrophy. — The  bilateral  hyper- 
trophy observed  in  virgins  after  puberty  may  be  observed  in  the 
breasts  during  pregnancy.  As  far  as  I  can  learn  from  the  literature, 
it  is  a  rare  condition.  If  these  breasts  produce  milk,  and  the  child 
nurses,  the  condition  as  a  rule  spontaneously  recovers.     If,  however, 


564  REGIONAL   SURGERY 

there  is  no  secretion  of  milk,  spontaneous  recovery  rarely,  if  ever, 
takes  place. 

Lactation. — The  predominant  lesion  of  the  lactating  breast  is 
mastitis.  The  portal  of  entrance  of  the  infection  is  through  the  in- 
jured nipple.  The  suckling  child  is  apt  to  injure  the  nipple  within  the 
first  few  months.  Lactation  mastitis  is  most  frequent  within  the  first 
month,  and  very  rarely  observed  after  the  fourth  month. 


Fig.  302. — Galactocele — a  single  cyst  containing  milky  fluid.     The  breast  contains  dilated 

ducts  with  milky  fluid. 

Pathol.  No.  10948. — 1910,  complete  operation  for  cancer  on  account  of  retracted  nipple 
and  red,  adherent  skin. 

White,  female,  aged  40;  a  mastitis  in  this  breast  many  years  ago  leaving  retracted  nipple; 
at  the  time  of  the  operation  patient  was  nursing  child  two  years  of  age.  Tumor  observed 
three  months.  Rapid  growth;  painful  and  tender.  The  changes  in  the  skin  were  probably 
due  to  an  infection  of  the  galactocele.  The  microscopic  study  shows  chronic  mastitis 
(see  Fig.  314)  and  dilated  ducts  (see  Fig.  318)  and  some  areas  of  lactation  hypertrophy  (see 
Fig.  323)- 

A  lump,  or  a  "cake,"  or  an  induration  of  the  breast  in  the  first 
four  months  of  lactation  may  at  first  be  looked  upon  as  mastitis. 
We  should  expect  in  such  a  palpable  area  resolution  (spontaneous 
disappearance),  or  the  formation  of  a  definite  abscess  (relieved  by 
incision).  If  one  of  these  two  things  does  not  take  place  within  two 
weeks,  one  should  be  suspicious  of  malignancy.     The  area  should  be 


LESIONS    OF   THE    FEMALE  BREAST 


565 


explored.  The  chronic  mastitis  abscess  (Fig.  303)*  and  galactocele 
(Fig.  302)  must  be  distinguished  in  the  gross  from  the  cancer  cyst  (Fig. 
305).  Tuberculosis  (Fig.  304)  may  be  recognized  by  the  abscess. f 
The  non-suppurating  chronic  mastitis  is  most  difficult  to  differentiate 
from  cancer.  The  benign  tumor  will  be  found  encapsulated  (Fig.  306) . 
The  dilemma  here  will  come  in  the  frozen  section  (Fig.  307). 


Fig.  303. — Chronic  mastitis  in  a  lactating  breast,  from  the  wall  of  a  chronic  lactation 

mastitis  abscess. 

Pathol.  No.  228. — 1893,  excision  of  cyst;  later  complete  operation  for  cancer,  on  account 
of  the  microscopic  picture  shown  here.      19 16,  23  years,  well. 

White,  female,  aged  29;  nursing  child  four  months  old;  tumor  two  months.  Clinically 
and  gross  a  chronic  abscess;  surrounding  breast  shows  normal  lactation  with  a  zone  of  mas- 
titis adjacent  to  abscess  cavity. 

In  lactation  the  nipple  should  always  be  protected.  When  the 
cake  appears  massage  is  not  sufficiently  beneficial  in  mastitis  to  justify 
its  employment  while  it  would  be  distinctly  dangerous  if  the  lesion 
were  malignant.  Cleansing  and  protection  of  the  infected  nipple 
are  the  most  important  things  in  the  treatment.  Bier's  hyperemia, 
ice,  or  the  hot- water  bag  may  be  employed.  My  personal  experience 
is  too  limited  to  speak  authoritatively.  I  have  confined  my  treat- 
ment to  the  nipple  and  to  ice  and  have  been  surprised  at  the  large 

*  All  these  photographs  were  taken  by  Mr.  Herman  Schapiro. 

t  Tubercular  mastitis  without  abscess  shows  no  caseation.  It  resembles  lactation 
mastitis  without  abscess.  Both  suggest  infiltrating  carcinoma.  Both  in  the  gross  and 
the  frozen  section. 


566 


REGIONAL    SURGERY 


Fig.  304. — Tuberculous  abscess  of  breast.     Cavity  lined  by  tuberculous  granulation 

tissue. 
Pathol.  No.  19066. — Operation  in  1916,  complete  excision  of  the  breast. 


Fig.  305. — Cancer  cyst  in  senile  breast. 
Pathol.  No.  7665. — Complete  operation  for  cancer. 


LESIONS  OF  THE  FEMALE  BREAST 


567 


number  of  cases  of  spontaneous  disappearance.  If  ice  should  give 
discomfort — do  nothing.     On  the  first  signs  of  pus — incise. 

For  abnormalities  in  lactation,  especially  the  scanty  secretion 
of  milk,  I  shall  take  no  space. 

Mastitis. — The  history  of  "caking"  of  the  breast  during  lactation,  of 
a  definite  mastitis  which  disappeared  spontaneously,  or  of  an  abscess 
which  was  incised  or  ruptured  spontaneously,  must  be  considered  in 
the  differential  diagnosis. 

The  history  of  a  lump  appearing  during  lactation,  or  remaining 
after  lactation  is  suggestive  of  a  galactocele  (Fig.  302).  At  the  present 
time  our  records  are  meager  in  regard  to  this  interesting  breast  lesion. 

Malignant  tumors  of  the  breast  have  apparently  no  relation  to 
a  mastitis  which  disappears  spontaneously,  or  forms  an  abscess  which 
heals.     However,  if  the  induration  in  the  area  of  the  mastitis,  whether 


Fig.  306. — Encapsulated  fibroadenoma  removed  with  a  zone  of  breast;  stroma  in  excess. 
Pathol.  No.  9340. — Operation  in  1908.     White,  female,  aged  19;  tumor  four  weeks.     In 

191 6,  eight  years,  well. 

there  has  been  an  abscess  or  not,  does  not  disappear,  cancer  may 
develop  in  this  area  (Fig.  308). 

These  two  facts — the  occurrence  of  galactocele  and  cancer  in  old 
scars  after  mastitis — represent  additional  evidence  to  emphasize  the 
dictum  that  no  lump  in  the  breast  can  be  considered  innocent,  and 
except  in  girls  under  twenty-five  and  during  lactation,  every  lump  in 
the  breast  should  immediately  be  explored. 

In  the  lactating  breast,  in  view  of  the  common  occurrence  of 
mastitis,  we  are  justified  in  watching  the  indurated  area  for  a  short 
period,  but  in  the  absence  of  complete  resolution  or  pus  formation, 
the  doubtful  area  should  be  explored.  When  there  are  indurated 
scars  after  a  mastitis,  these  should  be  excised  with  a  good  margin  of 
healthy  breast. 

Mastitis,  except  during  lactation,  is  a  rare  disease,  and  one  should 
never  make  a  clinical  diagnosis,  but  should  explore  the  area. 


568 


REGIONAL    SURGERY 


Fig.  307. — Lactation  hypertrophy  in  an  encapsulated  fibroadenoma. 
Pathol.  No.  15518. — Operation  in  1914,  excision  of  tumor  and  zone  of  breast.     White, 
female,  aged  20;  tumor  three  months;  patient  pregnant  two  months.     1916,  two  years,  well. 
Pregnancy  and  lactation  not  disturbed  by  operation. 


Fig.  308. — Scirrhous  carcinoma  developing  in  the  scar  residual  from  chronic  mastitic. 
The  ducts  with  their  thickened  walls  preserved. 


LESIONS    OF   THE    FEMALE   BREAST  569 

Mastitis  and  Lactation. — Lactation  may  persist  if  the  child  is  allowed 
to  nurse,  in  spite  of  the  presence  of  single  or  multiple  abscesses.  Nor 
do  the  latter  necessarily  interfere  with  lactation  after  a  subsequent 
pregnancy. 

Menstruation. — The  relation  of  breast  lesions  to  diseases  of  the 
pelvic  organs  needs  much  more  data  before  it  can  be  defined.  We 
know  that  with  pregnancy  the  breast  immediately  undergoes  a  paren- 
chymatous hypertrophy.  The  fully  developed  secretion  of  milk,  to  be 
maintained,  is  apparently  dependent  upon  irritation  of  the  nipple. 
Lactation  ceases  and  the  breasts  return  to  normal  when  the  child 
ceases  to  nurse. 

There  is  some  evidence  to  suggest  that  there  may  be  parenchyma- ' 
tous   changes  in  the  breast  associated  with  pelvic  conditions  other 
than  pregnancy.     The  lesion  of  the  breast  called  chronic  cystic  mastitis 
is  most  frequent  during  the  period  called  the  menopause. 

The  relation,  however,  between  pelvic  lesions,  the  menstrual 
period,  and  breast  lesions  is  not  sufficiently  well  established  to  be 
helpful  in  the  differential  diagnosis. 

Menopause. — It  is  quite  true  that,  except  for  cysts  and  chronic 
cystic  mastitis,  benign  tumors  are  rare  after  the  menopause,  but  the 
number  of  the  former  (cysts)  is  sufficiently  large  not  to  justify  the 
complete  operation  for  cancer  of  the  breast  in  women  after  the  meno- 
pause without  exploratory  incision. 

Children. — Most  careful  studies  have  been  made  on  the  relation 
of  the  different  forms  of  breast  lesions  in  unmarried  women,  in  married 
women  who  have  borne  no  children,  in  married  women  who  have 
borne  children,  and  the  character  of  the  lactation  in  the  latter.  These 
data  are  rarely,  if  ever,  helpful  in  the  differential  diagnosis,  and  al- 
though of  interest  to  record,  they  must  not  be  allowed  to  weigh  much, 
if  at  all,  in  the  differentiation  between  a  benign  and  a  malignant  tumor. 
It  is  true  that  chronic  cystic  mastitis  is  much  more  frequent  in  the 
breast  which  has  never  lactated,  whether  there  had  been  pregnancy,  or 
not.  When,  therefore,  you  see  a  woman  reaching  the  menopause, 
whose  breasts  have  never  lactated,  who  comes  to  you  because  of  pain 
in  the  breast  and  the  feeling  of  an  indefinite  lump,  and  you  find  in  this 
and  in  the  other  breast  other  lumps  just  as  indefinite  as  the  one  the 
patient  has  felt,  you  probably  will  be  safe  in  diagnosing  bilateral  chronic 
cystic  mastitis,  for  which  operation  is  not  indicated  at  this  time.  I 
will  consider  this  point  again,  as  many  breasts  now  are  being  sacrificed 
for  certain  stages  of  this  disease. 


570  REGIONAL   SURGERY 

HISTORICAL  DATA 

Up  to  the  present  time  an  intensive  study  of  the  data  thus  briefly 
discussed  has  shown  that  with  rare  exceptions  they  cannot  be  depended 
upon  for  differential  diagnosis.  Perhaps  future  studies  may  find  some 
diagnostic  points.  I  am  confident  that  in  many  cases  precious  time 
has  been  lost  by  allowing  data  of  this  kind  to  influence  the  diagnosis 
and  the  decision  as  to  operative  intervention.  I  have  not  mentioned 
the  family  history  of  cancer  or  tuberculosis  and  purposely  so,  because 
its  presence  or  absence  should  have  no  influence  on  the  surgeon's 
conclusions. 

SYMPTOMS  OF  ONSET 

I  have  called  attention  to  these  in  the  first  paragraph.  The  most 
frequent  S3miptom  is  the  palpation  of  a  tumor,  and  if  we  could  educate 
women  to  pay  immediate  attention  to  this  one  message,  the  number  of 
deaths  from  cancer  of  the  breast  would  be  immediately  diminished. 
Confusion  has  been  caused  in  the  minds  of  women  by  other  possible 
symptoms,  especially  pain.  The  woman  usually  waits  for  pain,  and 
in  the  past,  when  a  physician  was  asked  to  see  the  lump,  he  usually 
waited  for  the  so-called  clinical  signs  of  cancer — retracted  nipple, 
adherent  skin,  ulceration;  and  he  thought  much  about  the  presence  or 
absence  of  palpable  glands  in  the  axilla. 

The  majority  of  women  are  warned  by  a  lump,  and  that  warning 
should  be  enough.  If  the  physician  can  feel  a  lump,  it  is  fortunate 
for  the  patient  if  nothing  else  can  be  made  out  on  examination. 

Pain. — Pain  is  neither  a  sign  of  cancer,  nor  necessarily  of  any 
dangerous  lesion  in  the  breast.  Pain  in  one  or  both  breasts  is  not 
uncommon  in  women  just  before  the  menstrual  period  and  disappears 
after  the  beginning  of  the  flow.  As  tinghng  of  the  breasts  may  be  the 
first  suggestion  of  pregnancy,  so  pain  in  the  breast  may  be  the  first 
warning  of  the  coming  menstrual  period.  Undoubtedly  many  women 
experience  these  discomforts  and  say  nothing  about  them. 

Up  until  1 910  I  have  records  of  but  five  patients  who  came  under 
observation  for  pain  only;  the  duration  of  this  pain  had  varied  from 
three  weeks  to  four  years.  In  none  of  these  cases  has  any  disease  of 
the  breast  developed.  Since  1910  there  are  records  of  12  cases;  the 
duration  of  the  pain  has  varied  from  four  days  to  two  years. 

The  most  common  factor  in  all  of  these  cases  is  that  the  women 
are  usually  approaching  the  menopause,  and  naturally  one  thinks  of 


LESIONS    OF    THE    FEMALE   BREAST  57 1 

chronic  cystic  mastitis.  We  know  that  at  autopsy  small  cysts  and 
dilated  ducts  are  present  in  at  least  25  per  cent,  of  the  breasts  of  all 
women  over  40  years  of  age. 

The  next  most  frequent  historical  fact  is  the  fear  of  cancer.  These 
patients  have  had  some  near  relative  or  friend  die  of  cancer,  and  then 
experienced  pain  in  the  breast.  In  our  seventeen  patients  there  are 
but  three  under  30  years  of  age;  the  youngest  was  twenty-three. 

The  thing  which  should  interest  us  most  is  whether  pain  in  the 
breast  is  a  forerunner  of  some  disease  and  if  so,  of  what  form. 

In  the  great  majority  of  cases,  when  pain  is  the  first  symptom 
and  tumor  the  second,  the  tumor  is  benign. 

Nevertheless  in  a  record  of  almost  1800  cases  there  is  not  a  single 
variety  of  benign  or  malignant  condition  of  the  breast  in  which,  in 
some  cases,  pain  had  not  been  the  first  symptom  observed. 

However,  if  nothing  is  found  on  palpation,  pain  is  not  an  indica- 
tion for  operation.  Of  course,  such  patients  should  be  carefully 
watched.  Future  intensive  investigation  may  disclose  a  few  instances 
in  which  pain  alone  may  be  relied  upon  as  an  indication  for  the  removal 
of  the  breast. 

Discharge  of  Blood  from  the  Nipple. — There  is  a  prevailing  view 
that  a  bloody  discharge  from  the  nipple  means  cancer,  and  that  the 
complete  operation  for  cancer  should  be  performed.  This  conclusion 
is  apparently  based  on  records  different  from  my  own,  or  on  incorrect 
observations. 

My  experience  shows  that  if  there  is  no  other  sign  or  symptom, 
except  discharge  of  blood  from  the  nipple,  there  is  no  more  indication 
for  operation  than  in  the  presence  of  pain  alone.  I  am  hopeful, 
however,  to  be  able  some  day  to  recognize  the  few  cases  in  which 
discharge  from  the  nipple  can  be  properly  interpreted  as  an  indication 
for  the  removal  of  the  breast. 

In  876  cases  of  cancer  of  the  breast  discharge  from  the  nipple 
has  been  the  first  symptom  in  but  16  cases  (less  than  2  per  cent.).  In 
the  majority  of  these  the  tumor  was  felt  at  the  same  time  or  within 
a  few  days  after  the  discharge  was  noted.  In  a  few  cases  the  interval 
was  months,  in  two  cases  only  was  the  interval  a  year. 

Among  716  cases  of  benign  tumors  of  the  breast  discharge  from 
the  nipple  has  been  the  symptom  of  onset  in  twenty-four  (slightly 
over  3  per  cent.).  In  the  majority  of  these  cases  the  tumor  proved 
to  be  an  intracystic  papilloma.     In  fact,  it  is   a   question  whether 


572  REGIONAL   SURGERY 

such  an  intracystic  papilloma  was  not  present  in  every  case  subjected 
to  operation. 

In  nine  cases  of  discharge  of  blood  from  the  nipple  in  which  nothing 
else  could  be  made  out,  no  operation  was  performed,  and  no  tumor 
developed.  In  this  group  there  are  four  cases  in  which  the  interval 
is  II  years  or  more;  the  others  are  more  recent — four  years  or  less. 
The  longest  duration  of  a  bloody  discharge  without  the  development  of 
a  tumor  was  three  years. 

We  have,  therefore,  no  evidence  that  discharge  from  the  nipple 
is  an  indication  of  mahgnant  disease,  but  cases  of  this  kind  should 
be  carefully  watched,  and  the  patient  should  be  instructed  how  to 
keep  the  nipple  scrupulously  clean. 

Retraction  of  the  Nipple.— The  sudden  appearance  of  retraction 
of  the  nipple  is  a  sign  of  entirely  different  significance  from  that  of 
discharge  of  blood  from  the  nipple.  It  is  usually  the  warning  of 
mahgnant  disease  of  the  breast.  It  may  be  present,  but  very  rarely, 
in  benign  conditions.  If  one  can  establish  that  the  retraction  of 
the  nipple  is  really  of  recent  appearance  and  is  not  a  congenital,  or 
old  afi'air  from  some  former  lactation  mastitis,  it  should  be  looked 
upon  as  indicating  a  malignant  tumor  in  the  breast  and  the  entire 
breast  removed,  or  the  complete  operation  for  cancer  done. 

Retraction  of  the  nipple  may  be  a  congenital  condition,  but  this 
type  of  depressed  nipple  as  a  rule  is  different  from  the  acquired  re- 
traction. Retraction  of  the  nipple  may  take  place  after  a  mastitis 
with  or  without  abscess  formation,  and  now  and  then,  when  the  child 
is  suddenly  taken  from  the  breast,  one  or  both  nipples  may  pull  in 
without  evidence  of  mastitis. 

In  a  few  instances  with  distinctly  benign  lesions  retraction  of 
the  nipple  has  been  the  first  symptom  observed,  chiefly  in  chronic 
cystic  mastitis. 

At  the  present  time  it  is  my  opinion  that  it  is  safer  to  look  upon 
this  type  of  retraction  of  the  nipple  as  a  definite  sign  of  cancer.  If 
nothing  else  can  be  made  out,  it  is  my  practice  to  completely  remove  the 
breast  with  the  pectoral  fascia  to  the  axilla;  to  clamp  the  axilla  and 
cut  it  off  with  the  cautery;  then  make  serial  sections  into  the  breast; 
if  cancer  is  found,  proceed  with  the  axillary  operation;  if  not,  remove 
the  axillary  tissue  beyond  the  clamp. 

If  cancer  is  not  found,  a  condition  of  the  breast  is  usually  present 
best  treated  by  complete  removal  of  the  breast. 

I  have  been  surprised  at  the  attitude  of  many  experienced  clin- 


LESIONS    OF   THE   FEMALE  BREAST  573 

,  icians  and  surgeons  towards  this  retraction  of  the  nipple  when  it 
has  been  the  only  sign  present.  Precious  time  has  been  lost  waiting 
for  the  appearance  of  the  tumor.  As  a  rule  in  these  cases  the  cancer 
is  in  the  nipple  zone  and  difficult  to  recognize  by  palpation,  or  the 
women  have  large,  fat  breasts,  and  the  little  scirrhus  is  too  deeply 
situated  to  be  recognized. 

Pain  and  discharge  from  the  nipple  are  messages,  but  require 
no  answer.  Retraction  of  the  nipple  is  a  message  which  should  receive 
immediate  attention. 

Ulceration  of  the  Nipple  (Paget's  Disease). — Years  ago  Paget 
described  a  number  of  cases  of  cancer  of  the  breast  assoc'ated  with 
ulceration  of  the  nipple.  In  this  special  group,  Paget  states,  the 
ulceration  of  the  nipple  has  begun  one  or  more  years  before  the  patient 
had  felt  the  lump  in  the  breast.  As  far  as  I  know,  there  are  no  recorded 
cures,  when  the  operation  has  been  performed  in  the  Paget  stage. 

The  sore  nipples  during  lactation  require  great  care  and  give  anxiety 
chiefly  in  relation  to  mastitis. 

There  may  also  be  a  syphilitic  ulceration  of  the  nipple  in  the 
nursing  mother,  but  other  symptoms  on  the  part  of  mother  and  child 
should  excite  suspicion,  and  the  Wassermann  test  will  do  the  rest. 

Any  irritation,  or  eczema,  or  ulceration  about  the  nipple  and 
areola  should  receive  immediate  attention.  In  some  cases  copious 
use  of  soap  and  water  will  cure  the  disease.  In  others  there  will 
be  a  positive  Wassermann.  When  cleanliness  fails  to  relieve  and 
the  blood  examination  is  negative,  I  am  confident  that  it  will  be  safer 
to  look  upon  this  lesion  of  the  nipple  just  as  we  have  decided  to  regard 
retraction  of  the  nipple — as  a  sign  of  cancer.  Nothing  can  be  gained 
by  excising  a  piece  for  diagnosis,  or  completely  excising  the  nipple 
zone.  The  breast  should  be  removed  or  the  complete  operation  for 
cancer  performed.  Not  all  of  these  cases  are  cancer,  but  I  am  unable, 
from  the  available  data,  to  tell  how  to  differentiate  the  benign  from 
the  malignant.  I  am  confident  that  the  mutilation  should  be  con- 
sidered less,  than  the  greater  risk  of  any  conservative  operation. 

Subcutaneous  Fat. — In  the  normal  breast  the  nipple,  the  areola 
and  the  skin  are  freely  movable  over  the  deeper  structures,  and  there 
is  always  a  zone  of  subcutaneous  fat  between  the  skin  and  the  breast, 
except  beneath  the  nipple.  When  one  can  palpate  a  small  tumor,  the 
demonstration  of  absence  of  subcutaneous  fat  between  the  skin  and 
the  tumor  is  a  sign  of  malignancy.  In  large  tumors  it  is  possible 
to  have  an  atrophy  of  this  fat  from  pressure  in  lesions  distinctly  benign. 


574 


REGIONAL    SURGERY 


Atrophy  of  the  subcutaneous  fat  may  also  be  observed  in  pyogenic  and 
tuberculous  mastitis. 

The  demonstration  of  atrophy  of  the  subcutaneous  fat  is  rather 
an  expert  procedure;  it  is  one  of  the  earliest  signs  of  cancer. 

In  virginal  and  gravidity  bilateral  hypertrophy  the  parenchyma 
and  stroma  of  the  hyperplastic  breast  tissue  may  replace  the  subcutan- 
eous fat  and  bring  the  breast  tissue  immediately  beneath  the  skin. 
But  in  this  disease  it  is  not  a  sign  of  malignancy. 

Skin. — Only  once  have  I  observed  discreet  skin  metastasis  in  a 
breast  tumor  otherwise  apparently  benign,  and  in  this  case  the  two 


Fig.  309. — Bulging  of  tumor.     No  dimpling  of  skin  over  a  simple  cysl  in  chronic  cystic 

mastitis. 
Path.  No.  8579. — White,  female,  aged  52.     Tumor  one  year.     Operation,  1907,  excision 
of  cyst  and  zone  of  breast.     1916,  nine  years,  well. 


little  nodules  were  present  in  the  zone  of  skin  directly  over  the  breast 
tumor.  There  is  no  way  to  distinguish  a  single  metastatic  skin  nodule 
from  the  common  fibroma  of  the  skin.  Fortunately  the  latter  is  very 
rare  in  the  breast  area,  but  I  have  observed  two  cases  of  benign  breast 
tumors  in  which  there  were  also  present  single,  shot-like  skin  nodules 
which   were   fibromas.     This   possibiKty   should   be   borne   in   mind, 


LESIONS    OF   THE   FEMALE   BREAST 


575 


and  one  should  not  make  a  diagnosis  of  malignant  tumor  of  the  breast 
because  of  a  single  skin  nodule. 

The  changes  in  the  skin  which  are  rarely  associated  with  benign 
tumors  are  dimpling  and  slight  fixation.  The  dimpling  is  brought 
out  by  pushing  the  breast  with  the  palpable  tumor  with  both  hands 
(Figs.  309  and  310) .  Fixation  is  elicited  by  picking  up  a  bit  of  skin  over 
the  tumor. 

These  two  early  signs  of  cancer  have  now  and  then  been  observed 
in  benign  lesions,  especially  simple  cysts.- 


Fig.  310! — Dimpling  of  the  skin  over  the  bulging  tumor.     Small  infiltrating  scirrhus. 

Path.  No.  7973. — White,  female,  aged  54.     Tumor  six  weeks,  pain  10  days.     Complete 

operation,  1907.     No  metastasis  to  axilla.     1916,  nine  years,  well. 


Redness  and  definite  adhesion  of  the  skin  to  the  tumor  are  ob- 
served in  pyogenic  and  tuberculous  mastitis,  and  in  infected  cysts 
(which  are  very  rare).  In  the  vast  majority  of  cases  they  are  signs 
of  cancer.  Very  large  benign  tumors  (intracanalicular  myxoma)  may 
by  pressure  produce  ulceration  of  the  skin.  With  this  exception 
ulceration  is  an  almost  positive  sign  of  cancer. 

The  formation  of  a  sinus  or  sinuses  is  very  unusual  in  a  malignant 
tumor  of  the  breast.  It  is  very  common  in  tuberculosis  after  the 
sixth  month.  The  early  formation  of  a  sinus  favors  a  pyogenic  abscess. 
This  latter  should  heal  rapidly,  while  the  sinus  from  a  tuberculous  focus 
rarely  heals. 


576  REGIONAL    SURGERY 

When  a  malignant  breast  tumor  becomes  infected,  forms  an  abscess, 
becomes  adherent  to  the  skin,  ruptures  and  forms  a  sinus,  the  dif- 
ferential diagnosis  from  mastitis,  pyogenic  or  tuberculous,  is  practically 
impossible  clinically.  Although  it  is  very  rare  in  mahgnant  disease, 
the  evidence  seems  to  indicate  that,  in  cases  of  this  kind,  it  is  a  safer 
procedure  to  operate  for  cancer.  In  most  of  these  cases  the  breast 
must  be  removed  in  any  event.  In  a  few  instances  one  with  a  large 
experience,  having  recognized  the  benign  character  of  the  lesion, 
may,  with  comparative  safety,  perform  a  conservative  operation. 

In  a  few  instances  a  local  infection  in  the  skin  over  the  breast  may 
involve  the  deeper  tissues  and  produce  a  clinical  picture  suggesting 
mahgnant  disease.     Here  a  careful  history  will  be  helpful. 

The  later  changes  in  the  skin  associated  with  fully  developed 
cancer  should  give  rise  to  no  difficulty,  and  although  now  and  then 
these  may  be  associated  with  mastitis,  it  is  always  the  safer  pro- 
cedure to  operate  for  cancer.  These  more  definite  skin  changes 
are  the  so-called  "pig  skin,"  marked  induration,  multiple  dimpling, 
superficial  ulceration,  reddening,  dilatation  of  veins. 

CEdema  of  the  skin  and  subcutaneous  tissue  over  the  breast  is 
usually  a  sign  not  only  of  cancer,  but  of  hopeless  cancer.  I  have, 
however,  observed  it  twice  in  benign  conditions  of  the  breast.  In 
both  instances  the  breasts  were  large  and  pendulous,  the  induration 
of  the  breast  and  oedema  of  the  skin  and  fat  had  followed  a  trauma 
and  had  persisted. 

Axilla. — Too  much  importance  has  been  placed  upon  the  presence 
or  absence  of  palpable  nodules  in  the  axilla,  and  so  far  the  recent 
teaching  has  been  unable  to  overcome  the  older.  In  benign  lesions 
of  the  breast,  glands  are  frequently  palpable;  in  cancer  of  the  breast 
with  metastasis  to  the  glands  in  the  axilla,  one  may  be  unable  to  palpate 
glands. 

In  my  entire  experience  I  have  only  observed  one  case  in  which  the 
palpation  of  large  and  adherent  glands  in  the  axilla  led  to  a  diagnosis 
of  malignancy  even  in  the  absence  of  any  palpable  lump  in  the  breast. 
After  the  complete  operation  a  small  schirrous  cancer  was  found  in  the 
breast.     This  woman,  however,  had  a  large,  fatty  breast. 

In  a  small  number  of  cases  of  cancer  of  the  breast  the  patient's  atten- 
tion to  the  disease  has  been  attracted  by  the  nodules  in  the  axilla,  and 
the  tumor  of  the  breast  was  not  felt  until  later.  But  this,  of  course, 
does  not  exclude  the  presence  of  the  breast  tumor  at  that  time. 

When  one  feels  a  palpable  mass  or  a  number  of  enlarged  glands  in 


LESIONS  OF  THE  FEMALE  BREAST  577 

the  axilla  and  palpation  fails  to  reveal  any  trouble  in  either  breast,  there 
should  first  be  a  blood  examination  to  exclude  leukemia  or  syphilis. 
Having  excluded  these,  the  probabiHties  are  that  one  is  dealing  with  a 
primary  lesion  within  the  axillary  area.  The  number  of  such  cases  is 
small.  We  must  first  bear  in  mind  aberrant  breast  tissue.  Tumors 
of  this  kind  feel  like  lipomas.  I  will  discuss  them  later.  Then  there 
are  a  few  examples  of  hypertrophy  and  infection  of  the  axillary  sweat 
glands.  The  most  common  benign  tumors  in  the  axilla  are  lipoma  and 
fibromyxoma  of  nerve  sheaths. 

We  must  also  bear  in  mind  that  the  glands  may  be  enlarged  from 
pyogenic  or  tuberculous  infection  through  a  portal  of  entrance,  situated 
at  a  distance,  but  which  has  healed,  and  the  patient  may  have  forgotten 
the  incident.     (Healed  wounds  of  fingers.) 

Sarcoma  of  glands,  nerve  sheaths  and  fascia  are  possible. 

In  the  surgical  attack  on  axillary  masses  without  breast  involvement 
the  mistake  is  usually  made  of  performing  an  incomplete  operation  on 
the  clinical  diagnosis  of  a  benign  lesion.  If  these  cases  are  carefully 
considered,  one  should  be  able  to  recognize  those  in  which  a  complete 
axillary  dissection  offers  the  patient  the  best  opportunity  of  a  cure,  and 
in  my  experience,  whenever  such  an  axillary  dissection  is  indicated,  it 
is  best  to  perform  the  so-called  complete  operation  for  cancer  of  the 
breast. 

Supraclavicular  Glands. — The  involvement  of  these  glands  is  a 
late  occurrence  in  cancer  of  the  breast.  The  decision  as  to  when  to 
explore  the  neck  depends  less  upon  palpation  before  operation,  than 
upon  the  findings  within  the  axilla  at  operation.  This  will  be  discussed 
under  operation. 

Other  Breast. — Both  breasts  should  always  be  carefully  palpated. 
The  finding  in  the  other  breast  of  single  or  multiple  tumors  is  a  factor 
in  favor  of  benignity,  which  will  be  discussed  again  under  tumor. 

We  often  now  see  patients  with  a  lesion  of  one  breast,  and  a  history 
of  some  condition  in,  or  operation  on,  the  other  breast.  For  example, 
there  may  be  a  history  of  a  disappearing  tumor,  discharge  from  the 
nipple,  or  pain.  This  is  suggestive  that  we  are  dealing  with  a  bilateral 
lesion  which  in  the  majority  of  cases  is  benign,  usually  a  simple  cyst  or 
an  intracystic  papilloma. 

When  there  is  a  history  of  removal  of  a  tumor  from  the  other  breast 
and  no  evidence  of  recurrence,  we  have  evidence  that  this  tumor  at  least 
was  benign.  But  unless  we  have  absolute  proof  of  the  nature  of  this 
tumor,  we  are  not  helped.     Should  we  know  positively  that  the  removed 

37 


578  REGIONAL   SURGERY 

tumor  was  a  cyst  or  an  intracanalicular  myxoma,  this  e\'idence  would 
favor  a  benign  tumor  in  the  breast  under  examination. 

Among  almost  200  cases  of  simple  cysts  of  the  breast  we  have  seen 
cancer  of  the  remaining  breast  once  only.  This  indicates  that  if  a 
patient  has  a  cyst  in  one  breast  and  then  a  tumor  develops  in  the  other 
breast,  the  chances  are  that  the  second  tumor  is  also  a  cyst.  The  same 
is  also  true  of  intracanaHcular  myxoma. 

With  these  two  exceptions  the  knowledge  of  a  pre\dous  tumor  of 
the  other  breast  is  not  helpful,  except  when  we  know  that  the  first 
tumor  removed  was  a  cancer.  This  is  very  suggestive  that  the  present 
tumor  is  also  malignant. 

Our  observations  show  that  the  longer  our  patients  live  after  an 
operation  for  cancer  of  one  breast,  the  greater  the  probability  of  cancer 
of  the  other  breast.  As  yet  we  have  not  sufficient  evidence  to  prog- 
nosticate this  occurrence  and  to  justify  the  removal  of  the  other  breast 
as  a  protective  measure. 

Bilateral  diseases  of  the  breast  will  be  discussed  under  multiple 
tumors. 

Other  Organs. — I  have  no  evidence  that  would  be  helpful  in  the  dif- 
ferential diagnosis  of  breast  tumors  by  the  finding  of  lesions  elsewhere. 
In  older  literature  there  is  much  stress  laid  upon  cases  in  which  the 
symptoms  of  metastasis  were  the  first  signs  of  cancer  of  the  breast, 
especially  fracture  of  the  neck  of  the  femur  and  paralysis  of  the  lower 
limbs.  But  apparently  in  these  cases  the  breast  lesion  was  overlooked 
by  patient  and  physician  in  a  way  not  likely  to  occur  today.  The  only 
fact  that  has  impressed  me  in  a  long  observation  is  that  we  rarely  see 
cancer  of  the  breast  in  women  with  marked  tuberculosis  of  the  lungs, 
while  in  our  cases  of  tuberculosis  of  the  breast  lung  involvement,  if 
present,  is  slight. 

Vague  pains  in  the  chest,  in  bones  and  joints,  which  as  a  rule  are 
the  first  signs  suggesting  metastasis  after  operation,  cannot  be  inter- 
preted before  operation  as  an  indication  of  metastasis.  Again  and 
again  I  have  observed  them  before  operation  in  patients  who  have 
remained  well  years  after  the  complete  operation  for  cancer. 

Patients  with  lesions  of  the  breast  should  receive  a  most  careful 
general  investigation,  but  up  to  the  present  time  it  has  not  been 
especially  helpful  in  the  exact  diagnosis  of  the  condition  in  the  breast. 

I  am  now  investigating  the  relation  of  chronic  cystic  mastitis  to 
pelvic  lesions,  but  as  yet  have  obtained  no  definite  data. 

As  a  rule  our  patients  with  breast  tumors  are  good  operative  risks. 


LESIONS    OF    THE    FEMALE   BREAST  579 

One  should  always  think  of  the  ribs  below  the  breast  as  the  possible 
focus  of  the  breast  lesion.  I  have  seen  this  occur  but  twice.  Both 
were  instances  of  post-typhoid  perichondritis  in  which  the  pus  had 
infiltrated  the  breast.  In  one  of  these  at  exploration  we  found  an 
abscess,  in  the  other  an  encapsulated  bone  sequestrum. 

Single  Ttimor. — In  the  vast  majority  of  cases  the  patient  first 
observes  a  single  tumor,  and  if  she  seeks  advice  at  once,  this  is  all 
that  will  be  found  at  examination. 

I  have  learned  that,  when  a  woman  comes  under  observation  com- 
plaining of  a  breast  lesion,  it  is  a  safer  plan  to  at  first  take  no  history 
and  caution  the  patient  not  to  tell  you  which  breast  is  involved. 
In  the  past  two  years  this  plan  has  been  especially  useful  because  of 
the  greater  number  of  women  who  are  seeking  advice  early  for  vague 
pain,  indefinite  lumps  and  slight  weeping  from  one  or  both  nipples. 
If  after  examining  both  breasts  most  carefully  you  can  feel  no  distinct 
lump,  or  if  the  indistinct  area  which  you  feel  is  not  the  one  the  patient 
felt,  the  chances  are  there  is  no  definite  tumor.  When  a  patient  tells 
even  an  experienced  surgeon  that  she  has  a  lump  in  the  upper  and 
outer  quadrant  of  the  right  breast,  there  is  a  tendency  for  him  to  feel 
this  lump. 

The  breasts  of  many  women  are  lumpy.  This  is  most  marked  just 
before  and  in  the  beginning  of  menstruation  in  all  women.  In  un- 
married girls  palpation  produces  congestion  and  the  suspicion  of 
a  lump,  but  in  these  cases  the  age  under  twenty-five  helps  to  ex- 
clude cancer.  Now  and  then,  however,  such  breasts  are  explored  and 
no  tumor  is  found.  In  older  women  who  have  nursed  children  and 
in  younger  women  who  have  not,  lumpy  breasts  are  a  common  finding, 
especially  toward  the  menopause. 

Now  that  women  are  seeking  advice  so  early,  we  should  be  particu- 
larly anxious  not  to  overlook  a  single  tumor.  But  at  the  same  time 
we  do  not  wish  to  subject  them  to  unnecessary  operation. 

We  must  also  bear  in  mind  that  a  patient  may  have  felt  a  tumor, 
and  the  previous  examiner  may  also  have  been  correct,  but  when  you 
examine  the  patient  there  is  no  tumor.  You  may  also  feel  the  tumor 
at  your  first  examination  and  fail  to  find  it  at  the  next.  This  is  the 
disappearing  tumor — a  simple  or  papillomatous  cyst,  and  its  dis- 
appearance is  almost  as  good  a  cure  as  its  removal  by  operation. 

The  demonstration  of  a  definite  single  tumor  is  an  indication 
for  immediate  operation  when  the  patient  is  over  25  years  of  age, 
and  with  rare  exceptions  the  operation  is  also  indicated  in  women 


580  REGIONAL    SURGERY 

over  twenty.  The  function  of  a  breast  is  not  injured  by  the  removal 
of  a  single  tumor,  and,  if  this  tumor  is  benign,  the  patient  is  protected 
by  the  removal  of  a  precancerous  lesion. 

The  object,  however,  of  operating  upon  a  single  tumor  is  not 
so  much  to  remove  a  benign  lesion  as  to  expose  and  recognize  a  pos- 
sible cancer  in  a  period  when  the  chances  of  a  permanent  cure  are 
best. 

Disappearing  Tumors. — I  have  records  of  nine  cases  of  tumors 
which  have  disappeared  when  felt  after  a  most  careful  examination. 
The  age  of  these  patients  was  under  thirty  in  three,  in  four  it  was 
between  thirty  and  forty,  and  in  one  forty-five.  So  far  in  this  group 
no  other  tumors  have  appeared  in  the  same  or  the  other  breast.  In 
four  cases  it  is  now  from  7  to  22  years  since  the  first  observation. 

Among  174  cases  of  simple  cysts  in  chronic  cystic  mastitis  14 
cases  gave  a  history  of  a  disappearing  tumor  before  they  came  under 
observation.  Among  fifty-nine  of  these  174  cases,  in  which  the  cystic 
tumor  only  was  removed,  six  have  observed  a  disappearing  tumor  since 
operation. 

Among  50  cases  of  chronic  cystic  mastitis  without  large  cysts  found 
at  operation  only  two  gave  a  history  of  a  disappearing  tumor. 

Apparently  the  disappearing  tumor  is  a  simple  cyst.  When  a 
simple  cyst  has  been  removed  from  the  breast  and  a  second  tumor  ap- 
pears later  in  this  or  in  the  other  breast,  there  is  great  probabiHty 
that  this  is  another  cyst.  In  my  experience  it  has  been  cancer  in 
only  one  of  the  60  cases  when  both  breasts  were  saved,  and  one  out  of 
100  cases  when  one  breast  remained. 

Among  43  patients  whose  removed  tumor  proved  to  be  a  benign 
intracystic  papilloma  there  is  not  a  single  example  of  a  disappearing 
tumor  in  the  previous  history,  and  in  only  one  case  was  it  observed 
after  operation. 

Among  800  or  more  malignant  tumors  of  the  breast  we  have  recorded 
the  observation  of  a  disappearing  tumor  in  only  three  cases. 

The  history,  therefore,  of  a  disappearing  tumor  is  very  suggestive 
of  chronic  cystic  mastitis  with  cyst  formation.  But  I  would  not  allow 
this  to  influence  me  against  exploring  the  second  tumor  when  it  appears, 
because  there  is  a  possibility,  though  remote,  that  it  may  be  malignant. 

Multiple  Tumors. — The  correct  presentation  oj  the  problem  here 
Is  much  more  difficult  than  with  the  single  tumor.  The  number  of 
cases  is  relatively  small. 

The  most  significant  fact  is  that  among  the  cancers  of  the  breast 


LESIONS    OF   THE    FEMALE  BREAST  58 1 

the  majority  of  the  patients  presented  themselves  with  a  single  tumor 
in  one  breast. 

In  a  few  instances  there  were  multiple  tumors  in  one  or  both 
breasts.  These  observations  are  sufiS.cient  to  show  that  one  of  multiple 
tumors  in  one  or  both  breasts  may  become  malignant. 

The  most  common  multiple  tumors  of  the  breast  are  those  which 
have  the  least  tendency  to  become  malignant — the  simple  cyst  and 
the  intracanalicular  myxoma. 

If  one  palpates  distinctly  niore  than  one  tumor  in  a  breast,  or 
tumors  in  both  breasts,  at  least  one  tumor  in  each  breast  should  be 
explored.  One  should  select  the  tumor  of  longest  duration,  or  the 
largest,  or  the  one  most  suspicious,  on  palpation,  of  possible  malignancy. 
If  the  tumor  proves  to  be  a  simple  cyst,  or  an  intracanalicular  myxoma, 
or  a  lipoma,  I  think,  we  are  justified  in  removing  the  tumors  and  saving 
the  breast,  especially  in  younger  women.  We  have  a  number  of 
examples  of  the  removal  of  multiple  intracanalicular  myxomas  from 
one  or  both  breasts,  but  in  the  presence  of  multiple  simple  cysts,  the 
majority  of  surgeons  remove  the  entire  breast.  I  have  records  of  lo 
cases  only  in  which  multiple  simple  cysts  were  removed  from  one  or 
both  breasts.  These  patients  have  been  as  uniformly  relieved  as  the 
108  in  which  one  or  both  breasts  were  completely  excised. 

CLINICALLY  BENIGN  TUMORS 

When  the  surgeon  feels  unable  to  make  the  diagnosis  of  malignancy 
the  breast  lesion  for  practical  purposes  is  chnically  benign  (Fig.  309), 
There  is  no  necessity  for  a  border-line  group  of  clinically  doubtful 
tumors,  because  to  one  who  knows  there  is  always  an  element  of 
uncertainty. 

Some  surgeons  from  their  experience  may  be  better  able  to  elicit 
slight  fixation  of  the  nipple,  atrophy  of  the  subcutaneous  fat,  dimpling 
or  slight  fixation  of  the  skin  (Fig.  310),  when  the  less  experienced  one 
might  overlook  these.  Again,  experience  is  helpful  in  the  interpretation 
of  the  palpation  of  the  tumor  and  the  surrounding  tissue. 

No  surgeon  should,  however,  feel  too  sure  of  his  clinical  diagnosis. 
If  there  are  definite  clinical  signs  largely  favoring  malignancy,  the  opera- 
tion for  cancer  should  be  performed  without  an  exploratory  incision. 
The  number  of  mistakes  in  performing  this  for  a  benign  lesion  will  be 
relatively  very  small.  But,  on  the  other  hand,  if  all  the  signs  of  a 
malignant  tumor  are  absent,  it  is  not  justifiable  to  proceed  with  the 


582  REGIONAL   SURGERY 

complete  operation  for  cancer  without  excluding  a  benign  tumor  by  an 
exploratory  incision. 

The  per  cent,  of  benign  tumors  is  steadily  increasing,  in  my  observa- 
tion from  32  to  59  per  cent.,  and  if  every  woman  sought  advice  the 
moment  she  felt  a  lump  in  the  breast  the  proportion  of  benign  lesions 
would  be  still  greater. 

The  surgeon  today,  therefore,  must  prepare  himself  to  recognize 
breast  lesions  by  their  naked-eye  appearance,  with  or  without  the  aid 
of  a  frozen  section,  and  this  differential  diagnosis  is  more  difficult  than 
that  which  confronted  the  older  surgeons  in  the  cHnical  differentiation. 
Then  women  waited  as  a  rule  until  each  lesion  had  differentiated 
itself.  Now  women  are  coming  when  there  is  no  known  clinical 
differentiation,  and  recently  the  number  of  cases,  in  which  there  is  a 
great  dilemma  at  the  exploratory  operation  and  in  the  frozen  section,  is 
increasing. 

Personally  I  have  seen  in  the  past  two  years  more  non-encapsulated 
zones  of  the  breast  tissue  which  at  first  sight  felt  and  looked  Hke  cancer 
at  the  exploratory  incision,  which  were  very  suspicious  of  cancer  in  the 
frozen  section,  but  which  I  believe  are  not  cancer. 

Until  recently  we  explored  10  per  cent,  of  lumps  which  turned  out 
to  be  cancer;  now  we  are  exploring  as  many  as  40  and  50  per  cent. 
According  to  my  records  the  mistakes  of  performing  the  complete  opera- 
tion for  cancer  for  a  benign  lesion  were  until  a  few  years  ago  about  10 
per  cent.  In  the  hands  of  the  same  group  of  surgeons  today  it  has 
reached  almost  15  per  cent. 

The  mistakes  are  not  made  with  scirrhus  or  medullary  cancer,  but 
with  local  areas  of  mastitis,  chronic  cystitis  mastitis,  papillomatous 
cysts,  and  adenomas.  All  of  these  benign  lesions  are  on  the  increase, 
while  the  fully  developed  medullary  and  schirrhous  carcinoma  are  on 
the  decrease. 

When  the  benign  lump  is  explored,  it  is  best  for  the  patient  to  treat 
the  lesion  as  malignant,  unless  one  is  absolutely  certain  that  it  is  benign. 
Mutilation  is  nothing  as  compared  with  the  fatality  of  an  incomplete 
operation  for  cancer. 

To  recapitulate:  When  the  palpable  lump  is  associated  with  re- 
traction of  the  nipple,  dimpling  or  adherent  skin,  or  a  pretty  definite 
infiltration  of  the  surrounding  breast,  that  is,  the  usual  signs  of  cancer, 
it  is  by  all  means  best  for  the  patient  to  perform  the  complete  operation 
for  cancer. 

When  at  the  exploratory  incision  the  naked-eye  appearance  and  the 


LESIONS    OF   THE    FEMALE  BREAST  583 

frozen  section,  leave  you  in  doubt  what  to  do,  the  complete  operation 
for  cancer  is  best  for  the  patient. 

One  should  not  mistake  medullary  or  scirrhous  carcinoma  for  any 
benign  lump. 

Until  a  few  years  ago  my  evidence  indicated  that  if  you  removed  a 
cancer  of  the  breast  as  the  original  lump  only  and  then,  later,  after 
microscopic  study,  performed  the  complete  operation  for  cancer,  the 
chances  of  a  cure  were  reduced  from  about  80  to  10  per  cent. 

However,  in  recent  years  a  large  number  of  border-line  tumors  have 
been  sent  to  the  laboratory  for  diagnosis — cases  in  which  the  tumor  only 
had  been  removed.  In  this  group  there  were  no  fully  developed  cancers. 
In  some  cases  the  laboratory  diagnosis  was  benign,  and  no  further  opera- 
tion was  advised.  In  others,  on  account  of  suspicion  it  was  advised  to 
remove  the  breast.  In  still  others  the  diagnosis  of  early  adenocarcinoma 
was  made,  and  the  complete  operation  for  cancer  was  suggested. 

The  remarkable  fact  about  this  group  is  that  in  spite  of  what  diag- 
nosis we  made  and  what  operation  we  advised,  there  is  not  a  single 
death  from  cancer,  nor  a  single  recurrence.     ^ 

This  group  of  about  sixty  cases  has  been  submitted  to  many  patholo- 
gists throughout  the  country.  In  not  a  single  case  is  there  a  uniform 
agreement  as  to  the  diagnosis,  or  what  should  have  been  done. 

For  example,  some  of  the  encapsulated  tumors  which  we  had  con- 
sidered benign  cystic  adenomas  or  fibroadenomas,  other  pathologists 
have  diagnosed  cancer.  In  this  group  of  cases  the  tumors  only  were 
removed.  On  the  other  hand,  in  cases  which  were  considered  by  us 
early  adenocarcinoma  and  in  which  we  advised  the  complete  operation 
for  cancer,  the  consulting  pathologists  have  viewed  the  breast  lesion 
as  benign. 

This  introduction  is  absolutely  essential  to  what  follows. 

The  diagnoses  are  my  own,  but  it  is  important  for  the  reader  to 
know  that  in  the  border-line  group  there  are  some  pathologists  who 
agree,  and  some  who  disagree,  with  the  diagnoses  made.  The  thing  to 
bear  in  mind  with  great  emphasis  is,  that  no  patient  has  suffered  from 
this  disagreement,  except  now  and  then  from  an  unnecessary  removal  of 
the  breast. 

What  I  wish  to  emphasize  also  is,  that  the  operation  for  these  border- 
line tumors  in  two  stages  yields  just  as  good  results  as  in  one  stage,  and 
apparently  it  has  been  the  results  in  cases  of  this  kind  in  the  past  that 
have  impressed  surgeons  that  it  was  not  dangerous  to  operate  for  cancer 
of  the  breast  in  two  stages.     It  is  apparently  just  as  dangerous  today 


584  REGIONAL   SURGERY 

to  operate  for  fully  developed  cancer  in  two  stages,  but  it  is  not  danger- 
ous to  operate  for  a  benign  or  precancerous  lesion  in  two  stages.  In 
fact,  it  must  be  remembered  that  in  many  of  these  latter  cases  the 
second  operation  was  unnecessary.  I  am  confident,  however,  that  the 
complete  removal  of  the  breast  is  a  definite  protective  procedure  in 
certain  non-encapsulated  lesions  of  the  breast  which  may  be  included 
under  the  terms  chronic  mastitis  and  chronic  cystic  mastitis. 

CYSTIC  AND  SOLID  TUMORS  OF  THE  BREAST 

The  simple  cyst  (Fig.  311)  is  characterized  by  a  distinct  blue  dome, 
smooth  wall  and  non-hemorrhagic  contents;  the  papillomatous  cyst 
(Fig.  321)  by  the  intracystic  papilloma;  the  galactocele  (Fig.  302)  by 
its  milky  contents  and  smooth  wall.  The  chronic  pyogenic  abscess 
(Fig.  303)  contains  cloudy  material  and  has  a  wall  which  looks  like 
granulation  tissue.  The  tuberculous  abscess  (Fig.  304)  contains  the 
usual  pus  and  pretty  characteristic  granulation  tissue  in  the  wall. 

In  contrast  to  these  benign  cysts,  the  malignant  cyst  (Fig.  305), 
whether  cancer  or  sarcoma,  has  hemorrhagic  contents  without  papilloma, 
or  a  thick  grumous  material  entirely  different  from  the  contents  of  a 
pyogenic  or  tuberculous  abscess,  and  some  thick  area  in  its  wall  which 
an  expert  surgeon  could  select  for  frozen  section. 

The  solid  tumors  of  the  breast  must  be  divided  into  those  en- 
capsulated, circumscribed,  and  infiltrating. 

In  my  experience  distinct  encapsulation  is  a  sign  of  a  benign 
tumor,  usually  some  form  of  an  adenoma — cystic,  fibrous  or  intra- 
canalicular.  In  these  cases  one  is  helped  most  by  the  gross  appearance. 
The  histological  picture  of  the  intracanalicular  myxoma  is  the  least 
confusing;  that  of  the  cystic  and  fibrous  adenoma  is  frequently  inter- 
preted as  doubtful  or  malignant,  when  the  microscopic  appearance 
only  has  been  considered. 

Medullary  carcinoma,  scirrhus,  adenocarcinoma  and  sarcoma  may 
be  circumscribed.  The  gross  and  frozen-section  appearance  of  all 
but  adenocarcinoma  is  so  distinct  that  no  surgeon  should  today  ever 
make  the  mistake  of  performing  an  incomplete  operation  for  these 
forms  of  cancer  of  the  breast.  When,  however,  certain  benign  lesions 
resemble  these  more  malignant  forms  in  the  gross  appearance  or 
frozen  section,  the  mistake  of  the  complete  operation  will  have  to  be 
made. 

Certain  types  of  adenocarcinoma  are  easy  to  recognize :    The  colloid 


LESIONS    OF   THE   FEMALE   BREAST 


5^5 


from  its  intercellular  substance,  and  the  duct  cancer  (comedo  adeno- 
carcinoma) from  the  characteristic  worm-like  tubules  which  can 
be  expressed  from  the  cut  surface. 

The  type  of  adenocarcinoma  difficult  to  recognize  is  that  closely 
associated  with  cystic  adenoma,  a  more  or  less  circumscribed  tumor, 
and  chronic  cystic  mastitis,  a  diffuse  lesion. 

The  diffuse  benign  lesions  of  the  breast  are  most  difficult  of  all. 
We  have,  first,  during  lactation  the  chronic  mastitis  with  no  large  areas 


Fig.  311 . — Photograph  of  simple  cyst  surrounded  by  a  zone  of  breast.  Note  the  distinct 
cyst  wall,  smooth  surface,  one  dilated  duct  and  many  adenomatous  areas  of  surrounding 
breast. 

Path.  No.  19040. — White,  female,  aged  38.  Tumor  and  pain  three  weeks.  Opera- 
tion, 1910.  Excision  of  cyst  and  zone  of  breast.  1916,  six  years,  well.  This  photograph 
illustrates  how  a  simple  cyst  should  be  excised  after  it  is  explored. 


ofj,pus  formation.  Then,  in  the  non-lactating  breast  different  forms  of 
chronic  cystic  mastitis  and  chronic  mastitis  without  cyst  formation. 

I  shall  attempt  to  present  one  or  more  illustrations  of  the  different 
groups. 

At  this  time  I  again  wish  to  make  the  emphatic  statement  that 
in  the  great  majority  of  cases  a  decision  as  to  what  is  best  for  the  patient 
can  be  more  readily  made  from  the  gross  appearance.     Frozen  sections 


586 


REGIONAL    SURGERY 


can  be  made.     We  need  some  differential  staining  method  for  more 
exact  diagnosis. 

CYSTIC  TUMORS 

Simple  Cysts. — Usually  on  palpation  the  tumor  is  spherical  and 
tense  (Fig.  309)  and  suggests  a  cyst,  but  in  some  cases  when  it  is  buried 
in  breast  tissue  one  palpates  the  mass  of  breast  tissue  containing  the 
cyst,  and  the  area  feels  more  like  a  cancer  than  a  cyst. 

When  explored  carefully,  the  thin  cyst  wall  appears  as  a  blue  dome. 
One  may  pass  through  skin  and  fat  only,  before  the  cyst  wall  is  reached. 


Fig.  312. — Adenomatous   areas   in  zone  of  breast  removed  with  a  simple  cyst.     Some 

areas  show  beginning  ectasia. 

Path.  No.  16133. — ^White,  female,  aged  45;  tumor  and  pain  12  days.     Excision  of  cyst 

and  zone  of  breast.     1916,  well  two  years. 

or  also  through  a  zone  of  breast  tissue.  The  moment  the  thin  wall  is 
nicked  the  color  disappears.  The  lining  of  the  cyst  is  always  smooth; 
the  contents  clear  or  cloudy;  never  hemorrhagic,  nor  grumous,  thick 
material. 

The  cyst  wall  (Fig.  3 1 1 )  is  usually  thin ;  but  even  when  slightly  thicker, 
it  is  sharply  demarkated  from  the  breast  tissue.  When  this  cyst  is 
cut  out  with  a  zone  of  breast,  one  may  encounter  dilated  ducts  filled 
with  green,  gray  or  yellow  grumous  pastille  material,  other  cysts  of 
different  sizes,  and,  scattered  in  the  white  opaque  breast  tissue,  one 


LESIONS    OF   THE   FEMALE   BREAST 


587 


Fig.  313. — Irregular  adenomatous  areas  and  dilated  duct  in  breast  containing  multiple 

cysts  and  early  chronic  cystic  Inastitis. 
Pathol.  No.  16786. — White,  female,  aged  45;  pain  five  days,  tumor  four  days.     1915,  ex- 
cision of  zone  of  breast  containing  a  few  small  cysts.     1916,  one  year,  well. 


Fig.  314. — Area  of  chronic  mastitis  in  breast  near  wall  of  simple  cyst. 

Pathol.  No.  8717. — White,  female,  aged  45;  tumor  five  weeks,  one  week  after  trauma. 

1908,  complete  excision  of  breast  because  of  multiple  cysts.     1916,  eight  years,  well. 


588 


REGIONAL    SURGERY 


Fig.  315. — Area  of  ectasia  in  breast  containing  multiple  cysts  and  dilated  ducts. 

Pathol.  No.  9394. — White,  female,  aged  67;  tumor  and  pain  six  weeks.  Nipple  re- 
tracted; only  one  tumor  palpable.  1908,  complete  operation  for  cancer  based  on  retracted 
nipple.     Breast  contained  three  simple  cysts.     191 6,  eight  years,  well. 


Fig.  316. — Epithelium-lined  minute  c^^st  in  breast  containing  multiple  cysts  and  dilated 

ducts. 
Pathol.  No.  9394. — For  history  see  Fig.  315. 


LESIONS    OF    THE    FEMALE   BREAST 


589 


Fig.  317. — Adenocystic  areas  in  breast  containing  multiple  cysts  and  dilated  ducts. 
Pathol.  No.  9394.— For  history  see  Fig.  315. 


Fig.  318. — Dilated  ducts,  lined  with  basal  cells,  filled  with  grumous  material.    Breast, 

the  seat  of  multiple  cysts  and  dilated  ducts. 

Pathol.  No.  8717.— For  clinical  history  see  Fig.  314- 


590 


REGIONAL    SURGERY 


Fig.  31Q. — Area  of  duct  adenoma  in  zone  of  breast  about  a  simple  cyst. 

Pathol.  No.  14095. — White,  female,  aged  37;  pain  three  months,  tumor  one  month.    1913, 

excision  of  cyst  and  zone  of  breast.     191 6,  well. 


Fig.  320. — Area  of  duct  papilloma  in  chronic  mastitis  in  breast  about  a  simple  cyst. 
Pathol.  No.  16133. — White,  female,  aged  45;  tumor  and  pain  12  days.     1914,  excision  of 
cyst  in  zone  of  breast.     1916,  well. 

This  patient's  left  breast  had  been  removed  seven  years  before  apparently  for  a  simple 

cyst. 


LESIONS    OF   THE    FEMALE   BREAST  59I 

may  see  the  pink  elevated  dots  of  the  adenomatous  hypertrophy 
which  is  apparently  the  first  stage  of  the  chronic  cystic  mastitis.  The 
practical  point,  however,  is  that  in  an  experience  with  178  cases  there 
is  little  or  no  relation  between  this  cyst  and  cancer,  and  in  the  great 
majority  of  cases  the  breast  can  be  saved. 

However,  when  microscopic  sections  are  made  of  the  wall,  we  may 
find  all  stages  of  chronic  cystic  mastitis  (Figs.  312  to  320)  and  areas 
which,  if  we  did  not  know  the  gross  pathology,  might  be  considered 
sufficiently  suspicious  to  justify  the  removal  of  the  breast. 

It  is  frozen  sections  from  the  breast  about  these  blue-domed  cysts 
which  give  cellular  pathologists  their  dilemmas. 

Papillomatous  Cysts. — The  majority  of  surgeons  fear  to  do  a 
conservative  operation  for  a  cyst  with  a  papilloma,  especially  when 
it  contains  blood.  However,  if  these  papillomatous  cysts  are  sub- 
jected to  operation  in  the  early  benign  stage,  there  is  absolutely  no 
necessity  for  the  removal  of  the  breast.  The  cyst  is  not  blue-domed 
as  is  the  simple  cyst.  When  opened  it  usually  contains  blood-stained 
serum.  The  papillomata  may  be  of  variotis  sizes,  partially  or  com- 
pletely filling  the  cyst,  but  the  surface  is  always  papillomatous.  This 
is  lost  in  the  malignant  papilloma.  When  excising  the  benign  papil- 
lomatous cyst,  study  the  breast  tissue.  If  other  papillomatous  cysts 
are  encountered,  or  if  there  are  a  number  of  dilated  ducts  and  small 
cysts,  remove  the  breast,  a  procedure  which  is  not  followed  in  the  benign 
blue-domed  cyst.  If  the  breast  tissue  is  normal,  remove  the  cyst  only. 
Fig.  321  pictures  a  papillomatous  cyst  with  a  zone  of  breast  removed 
with  it.  After  one  has  removed  the  cyst,  its  wall  with  the  base  of  the 
papilloma  should  be  studied.  If  beneath  the  papilloma  there  is  no 
distinct  wall,  but  an  invasion  of  the  breast  by  the  papilloma,  im- 
mediately perform  the  operation  for  cancer. 

In  some  cases  of  papillomatous  cysts  thus  conservatively  treated 
many  pathologists  have  diagnosed  the  microscopic  section  cancer.  In 
the  case  represented  in  Fig.  322  there  has  been  no  recurrence  19  years 
after  the  excision  of  the  papillomatous  cyst  only. 

At  the  present  time  a  large  per  cent,  of  papillomatous  cysts  are 
treated  by  the  removal  of  the  breast,  or  the  complete  operation  for 
cancer.  Especially  now  that  women  are  coming  earlier  with  the 
lump,  this  mutilating  operation  should  be  performed  less,  and  without 
any  added  risk  to  the  patient. 

Galactocele,  a  cystic  tumor  due  to  the  accumulation  of  milk  in  a 
dilated  duct.     Clinically  I  have  never  been  able  to  make  out  the  bottle- 


592 


REGIONAL    SURGERY 


shaped  form  mentioned  in  the  literature.  To  have  a  true  galactocele 
there  must  be,  or  have  been,  lactation.  My  observations  show  that 
lactation  h3TDertrophy  may  persist  in  the  breast  14  years  after  nursing 
the  last  child  (Fig.  323).     Apparently  the  cause  of  this  is  some  local 


Fig.  321. — Benign  papillomatous  cyst  in  a  senile  and  fibrous  breast;  some  dilated  ducts 

and  chronic  cystic  mastitis. 
Pathol.  No.  17514. — White,  female,  aged  66;  tumor  after  trauma  eight  months;  no  dis- 
charge from  nipple.      On  account  of  the  slight  infiltration  of  the  skin  (probably  the  result  of 
the  trauma)  complete  operation  for  cancer  (1915).     1916,  one  year,  well. 


irritation,  such  as  a  galactocele,  a  benign  tumor,  or  a  chronic  mastitis. 
As  long  as  there  is  lactation  hypertrophy  in  the  breast  and  a  plugged 
duct,  galactocele  is  possible. 

In   the   20  years  previous  to  1910  we  observed  but  two  galacto- 
celes,  since  1910  twelve.     In  the  past,  therefore,  we  have  either  over- 


LESIONS    OF   THE   FEMALE  BREAST 


593 


Fig.  322. — Benign  papillomatous  cyst.     Section  from  papilloma. 
Pathol.  No.  1596. — Operation  in  1896,  excision  of  cyst  and  zone  of  breast. 
White,  female,  aged  45;  discharge  of  blood  from  nipple  15  years;  tumor  10  years.     1915 
19  years,  well. 

This  section  has  been  considered  by  many  pathologists  as  carcinoma. 


Fig.  323. — Area  of  residual  lactation  hypertrophy  and  dilated  ducts. 
Pathol.  No.  5088. — This  breast  was  also  the  seat  of  a  medullary  carcinoma. 
38 


594 


REGIONAL    SURGERY 


looked  galactoceles,  or,  on  account  of  delay,  the  patient  has  come 
under  observation  with  cancer.  As  a  rule  with  the  galactocele  the 
breast  is  the  seat  of  mastitis  or  areas  of  lactation,  or  there  may  be  multi- 
ple galactoceles  (Fig.  324).  In  the  majority  of  cases  the  condition  is 
mistaken  clinically,  at  the  exploratory  incision,  or  even  in  the  frozen 
section,  and  treated  as  malignant.  There  is  nothing  of  special  difficulty 
in  recognizing  the  galactocele  with  its  smooth  wall  and  milky  contents. 
But  when  the  breast  is  the  seat  of  mastitis,  areas  of  lactation  hyper- 
trophy, and  dilated  ducts  filled  with  creamy  material,  we  have  a  con- 


FiG.  324. — Multiple  galactoceles  and  dilated  ducts. 
Pathol.  No.  8166. — 1907,  excision  of  breast.  White,  female,  aged  34;  history  of  abscess 
in  this  breast  some  years  ago.  The  patient  is  nursing  her  child  aged  20  months.  Lacta- 
tion in  the  affected  breast,  scanty.  Lump  observed,  six  months.  In  addition  to  tumor 
multiple  nodules  in  breast.  After  operation,  cream-like  material  could  be  expressed  from 
the  dilated  ducts. 

fusing  picture,  and  the  probabilities  are  that  the  majority  of  surgeons 
will  do  the  complete  operation  for  cancer — the  safer  procedure.  It  is 
quite  possible  that  if  we  see  the  galactocele  quickly  as  was  my  good 
fortune  in  the  last  two  cases  of  two  and  five  weeks'  duration,  there  will 
be  but  a  single  palpable  tumor,  and  the  typical  cyst  will  be  recognized  on 
exploration.  Fig.  502  pictures  a  galactocele  in  which  the  condition  was 
treated  on  the  diagnosis  of  cancer.  Fig.  324  shows  the  diffuse  disease  of 
the  breast  — dilatation  of  all  the  ducts  often  associated  with  galactocele. 
Chronic  Lactation  Mastitis  Abscess. — This  disease  may  appear  as 
a  single  tumor,  and  at  exploration  as  a  single  cyst  (chronic  abscess)  in 


LESIONS  OF  THE  FEMALE  BREAST  595 

an  apparently  normal  lactating  breast.  The  contents  of  the  chronic 
mastitis  abscess  is  somewhat  purulent,  but  never  hemorrhagic  or 
grumous,  as  in  the  cancer  cyst.  Nevertheless  its  thick  wall  may  give 
rise  to  suspicion  of  cancer.  The  frozen  section  (Fig.  303)  is  to  many 
pathologists  even  more  confusing.  The  disease  should  be  distinguished 
from  cancer  in  the  gross.  When  the  breast  is  the  seat  of  chronic  mastitis 
with  remaining  areas  of  lactation  hypertrophy,  we  have  a  clinical, 
gross  and  microscopic  picture  so  difficult  to  recognize  with  certainty, 
that  I  would  advise  the  complete  operation  for  cancer.     There  is  little 


Fig.  325. — Adenocystic  changes  in  tubercular  mastitis,  suggesting  early  carcinoma. 

Pathol.  No.  3170. — Complete  operation  for  cancer  in  igoo.  White,  female,  aged  35;  pain 
three  months;  tumor  two  months;  sinus  one  month. 

Ten  years  later  the  patient  was  under  observation  with  tubercular  peritonitis.  No 
evidence  of  cancer. 

to  lose,  as  in  the  majority  of  these  cases  the  breast  must  be  sacrificed  in 
any  event. 

Tuberculous  Abscess. — We  are  rarely  given  the  opportunity  to  see 
a  tuberculous  abscess  of  the  breast  before  it  is  ruptured.  Tuberculosis 
of  the  breast  is  usually  a  single  focus  and  appears  first  as  an  area  of 
induration.  Softening  with  abscess  formation  takes  place,  as  a  rule, 
before  six  months  and  a  sinus  forms.  The  tuberculous  abscess  (Fig. 
304)  of  the  breast  does  not  differ  in  the  gross  from  the  same  lesion  any- 
where else.     However,  microscopically,  in  the  wall  of  the  cavity  the 


50 


l^EGIOMAL    SURGERY 


mastitis  secondary  to  the  tuberculosis  is  frequently  looked  upon  as 
adenocarcinoma  (Fig.  325).  I  have  never  been  able  to  conclusively 
prove  the  presence  of  cancer  in  any  tuberculous  abscess  of  the  breast, 
although  many  of  these  cases  had  been  diagnosed  and  treated  as  cancer. 
In  none  have  the  glands  shown  metastasis,  nor  have  any  of  the  patients 
died  of  cancer. 

Cancer  Cysts. — A  smooth-walled  cyst  with  bloody  contents  and 
without  a  papilloma  should  be  treated  as  cancer.  A  smooth-walled 
cyst  with  thick  grumous  material  is  always  malignant.     In  the  majority 


CG-'-'jCii^-i'  ,.- 


Fig.  326. — Typical  fully  developed  cancer  in  wall  of  cancer  cyst. 
Pathol.  No.  5252. — Operation  in  1904,  complete  for  cancer. 
White,  female,  aged  64;  pain  three  months;  tumor  two  months. 

of  cases  cancer  can  be  recognized  in  the  wall  of  these  cysts  at  the 
exploratory  incision. 

In  the  past  smooth-walled  cysts  containing  blood  were  the  cancer 
cysts  not  recognized  by  the  surgeons,  and  treated  as  benign. 

Figure  305  shows  a  somewhat  smooth-walled  cancer  cyst  which 
contained  blood. 

In  the  20  cases  of  cancer  cysts  observed  by  me,  fully  developed  car- 
cinoma or  sarcoma  was  readily  recognized  in  the  microscopic  section 
(Fig.  326). 


LESIONS    OF    THE    FEMALE   BREAST  597 

In  the  differential  diagnosis  of  the  different  types  of  cysts  one  is 
helped  most  by  the  contents  of  the  cyst,  by  the  character  of  the  wall, 
by  the  appearance  of  the  papilloma,  if  present,  and  by  the  careful  study 
of  the  base  of  the  papilloma.  There  should  really  be  little  difficulty 
in  recognizing  the  cancer  cyst,  but  when  the  benign  cyst  is  associated 
with  some  diffuse  disease  of  the  breast,  such  as  lactation  mastitis, 
chronic  cystic  mastitis,  multiple  galactoceles,  the  surgeon  is  usually 
confused  and  the  complete  operation  for  cancer  performed. 

SOLID  ENCAPSULATED  TUMORS 

The  benign  solid  encapsulated  tumors  are  cystic  adenoma,  intra- 
canalicular  myxoma  and  fibroadenoma.     The  common  characteristic 


Fig.  327. — Encapsulated  cystic  adenoma  removed  with  a  zone  of  breast. 
Pathol.  No.  2568. — Operation  in  1899.     White,  female,  aged  30;  tumor  10  years. 

which  differentiates  them  from  the  malignant  tumors  is  the  presence 
of  a  distinct  capsule.  One  could  enucleate  them  from  the  surrounding 
breast.  Often,  however,  at  one  point  the  capsule  is  less  distinct 
and  there  is  the  appearance  of  an  isthmus-like  connection  between 
the  tumor  and  the  breast.  I  have  never  observed  a  malignant  tumor 
with  such  a  capsule. 

In  the  cystic  adenoma  (Figs.  327  and  328)  one  sees  minute  cysts  through- 
out the  tumor.  Some  are  filled  with  clear  or  cloudy  fluid,  others  seem 
to  contain  a  granular  material  which,  as  a  rule,  does  not  express  on 
pressure.  Microscopically,  on  account  of  the  large  number  of  pictures 
met  with,  these  tumors  are  often  diagnosed  early  carcinoma,  and 
breasts  are  unnecessarily  sacrificed.  About  30  per  cent,  of  pathologists 
diagnosed  the  section  (shown  in  Fig.  329)  cancer.     In  this  case  for- 


598 


REGIONAL   SURGERY 


tunately  only  the  tumor  had  been  removed.     There  has  been  no  local 
recurrence  now  four  years  since  operation. 

The  fibroadenoma  shows  no  minute  cysts.  It  may  be  marked  by 
little  crevices  or  show  minute  dots,  and  in  addition  there  are  white 
and  gray  areas  (Fig.  306).  In  some  fibroadenomas  there  is  so  little 
stroma  (Fig.  330)  that  they  almost  resemble  a  miniature  pancreas. 
But  here  again  pathologists  have  been  found  to  disagree  in  the  micro- 
scopic study  (Fig.  331).  Here  the  diagnosis  of  malignancy  is  as  five 
to  two  benign. 


Fig.  328. — The  microscopic  picture  of  cystic  adenoma  and  chronic  cystic  mastitis. 

Pathol.  No.  9394. — For  clinical  history  see  legend  of  Fig.  315.    The  diflferent  types  of  areas 

in  this  zone  of  breast  are  designated  in  Figs.  315,  316  and  317. 

When  these  fibroadenomas  are  present  in  the  lactating  breast, 
they  undergo  lactation  hypertrophy  (Fig.  307),  and  here  the  frozen- 
section  diagnosis,  when  one  is  not  famiHar  with  lactation,  is  very 
confusing. 

The  fibroadenoma  situated  within  the  breast  rarely  reaches  great 
size  (a  characteristic  of  the  intracanahcular  myxoma) .  When  present 
for  a  number  of  years  the  fibroadenoma  may  become  calcified. 

Aberrant  Fibroadenomas. — The  most  frequent  tumor  observed  out- 
side of  the  breast  resembles  the  fibroadenoma.  It  may  often  attain 
a  size  larger  than  that  of  the  breast  (Fig.  301)  and  many  of  these  cases 
are  treated  on  the  diagnosis  of  sarcoma.     The  tumor,  however,  is 


LESIONS    OF    THE    FEMALE   BREAST 


599 


always  encapsulated.  Its  gross  appearance  is  typically  glandular 
(Fig.  332),  and  microscopically  it  differs  from  breast  tissue  at  puberty 
only  in  the  irregularity  of  the  arrangement  of  parenchyma  and  stroma 
(Fig.  333). 


'■y^.^-. 


y-^/^'jf^-^ 


Fig.  329. — Cystic  adenoma. 

Pathol.  No.  13599. — Operation  in  191 2,  excision  of  tumor  and  zone  of  breast.  191 6, 
four  years,  well. 

White,  female,  aged  22;  tumor  three  months.  Consulting  pathologists  differ  as  to 
diagnosis. 

Intracanalicular  Myxoma. — The  small  intracanaHcular  myxoma 
does  not  differ  much,  in  the  gross,  from  the  adenofibroma  (Fig.  334). 
In  a  few  instances  the  tumor  looks  so  succulent  that  it  gives  one  the 
impression  of  a  medullary  carcinoma.  Here  a  frozen  section  will  be 
most  helpful,  because  there  is  nothing  more  characteristic  than  its 
histology  (Fig.  335). 


6oo 


REGIONAL   SURGERY 


I  have  been  told  about,  but  have  never  seen,  a  perfectly  encapsulated 
medullary  carcinoma.  If  there  be  such  a  thing,  the  frozen  section 
will  immediately  differentiate  it.     As  the  intracanalicular  myxoma 


Fig.  330. — Small  encapsulated  fibroadenoma,  excised  with  a  zone  of  breast;  stroma, 

scanty. 
Pathol.  No.  19063. — White,  female,  aged  40;  tumor  a  few  months.     Operation  in  1916 
excision  of  tumor  with  zone  of  breast. 

For  microscopic  appearance  see  Fig.  333. 


r^^ 


Fig.  331. — Fibroadenoma,  Consulting  pathologists  differ  as  to  diagnosis.  The  tumor 
was  a  small,  distinctly  encapsulated  area  in  the  breast  of  a  young  girl  under  twenty-five. 
Pathol.  No.  19060. — Excision  of  tumor  only. 


grows  larger,  its  peculiar  gross  appearance  becomes  more  characteristic. 
In  this  middle  stage  it  has  neither  the  cysts  of  the  cystic  adenoma, 
nor  the  splits  of  the  adenofibroma,  but  rather  the  appearance  of  the 
hypertrophied  prostate. 


LESIONS    OF   THE    FEMALE   BREAST 


6oi 


The  gross  appearance  of  the  large  intracanalicular  myxoma  may 
bsM variegated  (Fig.  336),  but  there  is  no  necessity  for  any  attempt  at 
diagnosis  before  operation:  These  large,  apparently  encapsulated 
tumors  occupying  more  than  one-fourth  of  the  breast  should  be  treated 
as  sarcoma — the  tumor,  breast,  an  area  of  skin  and  the  greater  pectoral 
muscle  should  be  removed. 


Fig.  332. — Encapsulated,  large,  aberrant  fibroadenoma,  incorrectly  diagnosed  sarcoma. 
Pathol.  No.  6060. — Operation  in  1904,  complete  for  sarcoma.     Colored,  girl,  aged  17; 
small  tumor  observed  shortly  after  birth;  rapid  growth  since  puberty  for  three  years. 
1916,  twelve  years,  well. 


These  three  adenomas  of  the  breast  should  offer  but  little  diagnostic 
difi&culty  at  the  exploratory  incision.  The  chief  characteristic  is 
encapsulation. 

Malignant  tumors  may  be  circumscribed,  but  they  can  never  be 
enucleated  from  the  surrounding  breast  tissue,  and  when  one  explores 
a  solid  tumor  which  is  not  encapsulated,  one  should  treat  such  a 
tumor  as  malignant. 

Until  recently  all  the  distinct  solid  tumors  which  were  not  en- 


6o2 


REGIONAL    SURGERY 


capsulated  and  which  were  explored  by  me  were  malignant.     Now  that 
I  am  seeing  cases  earlier  I  have  met  with  a  number  that  are  benign. 

Circumscribed,  but  not  Encapsulated  Benign  Tumors. — Figure  337 
represents  such  a  tumor  which  I  explored  in  191 5.  There  was  no 
capsule,  it  felt  to  the  finger  like  cancer,  and  gave  the  gritty  sensation 


Fig.  233- — Microscopic   picture  of   the  usual  aberrant  fibroadenoma.       For   gross   ap- 
pearance and  history  see  Fig.  330. 

of  a  scirrhus  under  the  knife.  This  lump  had  been  in  the  breast 
perhaps  20  years,  but  in  the  last  few  weeks  had  seemed  to  grow 
and  had  become  painful.  The  microscopic  appearance  is  shown  in 
Fig.  338. 

We   may   also   observe   circumscribed   areas   of   chironic   mastitis, 
chronic   cystic   mastitis,    cystic   adenoma    and   fibroadenomas   which 


LESIONS    OF    THE    FEMALE    BREAST  603 

have  lost  their  capsule.  Now  that  women  as  seeking  advice  earlier 
after  the  first  appearance  of  the  tumor,  or  more  quickly  after  the 
first  change  in  an  old  tumor,  this  new  group,  most'difficult  to  diagnose, 


Fig.  334. — Encapsulated  intracanalicular  myxoma. 
Pathol.  ]^o.  18374. — Operation  in  1915,  excision  of  tumor  and  zone  of  breast. 

will  increase.     So  far  all  the  cases  recorded  by  me  have  been  treated 
on  the  diagnosis  of  early  cancer. 

Chronic  Cystic  Mastitis. — This   disease  may  appear   as   a :,  blue- 
domed  simple  cyst  (Fig.  311)  such  as  I  have  described.     Apparently 


Fig.  335.^ — Microscopic  appearance  of  intracanalicular  myxoma. 
Pathol.  No.  2761. 

this  is  by  far  the  most  common  condition.  Chronic  cystic  mastitis  is 
probably  present  in  many  breasts,  but  not  until  a  cyst  forms  is  the 
patient  aware  of  it.     Previous    to    the    formation    of  the  cyst  these 


6o4  REGIONAL    SURGERY 

patients  may  experience  pain.  At  the  present  time  we  are  seeing 
many  women  with  painful  breasts,  more  than  ever  before.  Again, 
we  are  seeing  a  number  of  cases  of  painful  breasts  in  which  on  ex- 
amination we  find  one  or  more  nodules  in  one  or  both  breasts.     True, 


Fig.  336. — Large  encapsulated  intracanalicular  myxoma,  which  usually  shows  sar- 
comatous changes  and  should  be  treated  as  sarcoma. 
Pathol.  Xo.  17979- — Operation  in  1915,  excision  of  tumor  only,  later  on  advice  from 
Pathological  Laboratory,  complete  excision  of  scar  and  pectoralis  major  muscle. 
White,  female,  aged  39,  tumor,  two  years.     1916,  one  year,  well. 

the  nodules  are  rather  indefinite  to  the  experienced,  but  are  often 
considered  tumors  by  the  patient  and  inexperienced  physician  or 
surgeon.  When  we  feel  a  definite  tumor,  explore  it,  and  find  the  blue- 
domed,  smooth-walled  cyst  (Fig.  311)  we  have,  as  I  have  stated  before 
and  wish  to  repeat  here  again,  clinical  and  gross  evidence  of  a  benign 


LESIONS    OF   THE    FEMALE   BREAST 


60: 


lesion.  As  we  cut  out  these  simple  cysts  or  when  we  examine  the  re- 
moved breast,  we  always  find  evidence  of  a  diffuse  disease  of  the 
breast:     There  are  minute  cysts  of  various  sizes,  dilated  ducts  filled 


Fig.  337. — Circumscribed,  but  not  encapsulated  cystic  adenoma.     Gross  appearance  at 
exploratory  incision  suggested  cancer. 
Pathol.  No.  17012. — Operation  in  1915,  exploration  followed  by  complete  operation  for 
cancer.     White,  female,  aged  30;  little  tumor  20  years;  recent  growth  and  pain  two  weeks 
For  microscopic  appearance  see  Fig.  338. 

with  grumous  material;  pink,  elevated  dots.  These  may  be  scattered 
in  the  breast  tissue,  rather  diffusely  mixed  with  the  fibrous  stroma. 
In  cases  of  this  kind  thev  make  Uttle  impression  upon  the  ordinary 


Fig.  338. — Cystic  adenoma.     For  gross  and  clinical  note  see  Fig.  317. 
Compare  this  section  with  Figs.  328,  329,  and  319. 

observer.  However,  we  may  meet  the  disease  as  a  circumscribed  area 
when  it  has  the  exact  appearance  of  a  cystic  adenoma,  except  that  it 
is  not  encapsulated.     A  quadrant  or  a  hemisphere,  or  the  entire  breast 


6o6 


REGIONAL   SURGERY 


may  be  involved  in  this  parenchymatous  change  (Fig.  339).  It  has 
received  many  names — Schimmelhuscli' s  or  Rectus^  disease,  abnormal 
involution,  senile  parenchymatous  hypertrophy.  I  prefer  to  return  to 
the  old  terminology  of  Billroth — chronic  cystic  mastitis.  This  patho- 
logical process  impresses  me  as  a  reaction  to  some  irritant.  Micro- 
scopically and  in  addition  to  the  parenchymatous  changes,  there  is 
evidence  of  reaction  in  the  stroma  of  the  breast.  No  relation  between 
this  disease  and  any  microorganism  has  yet  been  established. 

In  a  smaller  group  of  ca3es  there  are  no  large  simple  cysts  (Fig.  339). 
In  this  group  before  operation  we  may  palpate  an  indistinct  tumor, 
a  distinct  circumscribed  area,  or  a  diffuse  shot-like  mass  involving  a 
quadrant,  a  hemisphere  or  the  entire  breast. 


Fig.  339. — Chronic  cystic  mastitis;  no  large  cysts.  N  =  normal  breast;  C  =  minute 
cysts;  X  =  areas  suspicious  of  adenocarcinoma;  Ad  =  adenocystic  areas. 
Pathol.  No.  3965. — Operation  in  1901,  complete  excision  of  breast.  1916,  15  years> 
well.  White,  female,  aged  40;  pain  six  months,  nodular  enlargement  of  one  quadrant  four 
months.  Slight  discharge  from  nipple.  After  microscopic  study  of  this  breast  the  complete 
operation  was  advised,  but  refused  by  patient.  For  microscopic  appearance  see  Figs.  312 
to  320  and  Figs.  328,  329  and  331. 


When  we  study  these  areas  microscopically  we  find  a  great  variety 
of  histological  pictures,  difficult  to  interpret. 

Until  three  years  ago  about  50  per  cent,  of  the  cases  of  chronic  cystic 
mastitis  without  large  cysts  were  looked  upon  as  malignant,  in  the  past 
three  years  only  30  per  cent. 

As  we  have  no  exact  method  of  differentiating  the  benign  from  the 
malignant,  I  am  convinced  that  it  is  safer  in  these  cases  to  radically 
remove  the  entire  breast  with  the  pectoral  fascia.  If  there  is  any 
evidence  of  cancer,  operate  as  you  would  for  cancer. 

The  time  may  come  when  we  will  be  able  to  differentiate,  but  at 
the  present  time  I  am  convinced  that  this  is  the  safest  procedure. 

It  seems  strange  that  in  the  larger  group,  when  we  find  a  definite 


LESIONS    OF   THE    FEMALE   BREAST  607 

smooth-walled  cyst,  experience  shows  that  it  is  justifiable  to  perform 
the  conservative  operation  of  excision  of  the  cyst  with  a  zone  of  breast 
tissue.  However,  in  the  smaller  group  when  we  find  no  such  cysts,  but 
a  circumscribed  or  diffuse  area  of  the  cystic  mastitis,  experience  teaches 
us  that  it  is  safer  to  remove  the  breast. 

A  most  thorough  gross  and  microscopic  study  of  almost  300  such 
cases  shows  not  much  difference  in  the  breast  about  the  simple  cyst,  in 
the  chronic  cystic  mastitis  without  large  cysts,  and  in  the  chronic 
cystic  mastitis  associated  with  definite  carcinoma. 

I  have  submitted  a  large  number  of  these  cases  to  a  group  of  experi- 
enced pathologists  and  found  a  great  divergence  of  opinion.  It  would, 
therefore,  be  a  mistake  to  present  this  disease  as  a  well-established 
entity  in  which  exact  diagnosis  is  possible. 

Cancer  in  Chronic  Cystic  Mastitis. — In  18  cases  of  cancer  cysts  the 
presence  of  chronic  cystic  mastitis  in  the  surrounding  breast  has  been 
conspicuous  by  its  absence.  So  we  have  no  evidence  that  the  cancer 
cyst  begins  in  this  disease. 

When  scirrhus  and  medullary  carcinoma  predominate  in  the  picture 
of  the  tumor,  one  pays  little  attention  to  the  surrounding  breast,  as  an 
indication  for  operation. 

In  those  cases  in  which  at  the  exploration  we  do  not  find  a  zone  oi 
scirrhous  or  medullary  carcinoma,  but  an  area  of  chronic  cystic  mastitis 
as  pictured  in  Fig.  339,  the  difficulties  of  differential  diagnosis  in  the 
majority  of  cases  are  sufficient  to  justify  the  complete  excision  of  the 
breast,  and  in  some  cases  the  complete  operation  for  cancer. 

In  50  cases  we  have  made  the  diagnosis  of  benign,  chronic  cystic 
mastitis.  As  far  as  I  know,  not  a  single  one  of  these  patients  has  subse- 
quently died  of  cancer.  In  13  of  these  cases  the  small  zone  which 
was  palpated  before  operation  did  not  show  the  fully  developed  chronic 
cystic  mastitis  as  illustrated  in  Fig.  330,  but  rather  the  character  of  the 
breast  tissue  pictured  in  Fig.  321.  Microscopically,  the  tissue  excised 
showed  evidence  of  the  adenomatous  stage  only  (see  Fig.  312).  I  am 
inclined  to  think  that  careful  scrutiny  at  the  exploratory  incision  with 
the  aid  of  a  frozen  section  will  distinguish  these  cases  and  allow  a 
conservative  operation. 

In  18  cases  the  breast  was  completely  removed,  in  6  both  breasts, 
and  in  13  the  complete  operation  for  cancer  was  done. 

It  is  true  that  in  some  of  these  cases  there  was  no  indication  for 
either  the  removal  of  the  breast  or  the  complete  operation  for  cancer, 
because  gross  and  microscopically  the  tissue  removed  resembled  that  in 


6o8 


REGIONAL    SURGERY 


the  first  group.  But  in  the  majority  of  cases  the  gross  appearance  of 
the  palpable  and  explored  area  corresponded  pretty  closely  to  that 
shown  in  Fig.  339,  and  the  microscopic  to  that  in  Figs.  312  to  320. 

It  is  interesting  to  note,  however,  that  the  breast  in  these  50  cases 
diagnosed  benign  chronic  cystic  mastitis  differed  very  little,  except 
in  degree,  from  170  cases  diagnosed  simple  cyst  in  chronic  cystic 
mastitis.  It  is  very  difficult  to  explain  the  development  of  the  large 
cyst  in  the  larger  group. 

In  128  cases  single  simple  cysts  similar  to  that  illustrated  in  Fig.  311 
were  present.  In  54  of  these  cases  only  the  cyst  and  a  zone  of  the 
breast  was  excised.  In  one  of  these  cases  three  years  later  a  cancer 
formed  in  another  zone  of  the  breast.     The  patient  presented  herself 


Fig.  340. — Chronic  cystic  mastitis  with  muitipie  cysts. 

Pathol.  No.  15359. — Complete  operation  for  cancer  in  1913.     White,  female,  aged  45; 

pain  15  months;  tumor  one  year  (disappeared  once).     1916,  three  years,  weU. 

immediately,  it  was  recognized  at  the  exploratory  incision,  and  the 
patient  is  well  five  years  since  the  complete  operation  for  cancer. 
The  microscopic  appearances  of  the  breast  about  these  cysts  is  shown  in 
Figs.  312  to  320. 

In  forty-eight  cases  for  various  reasons  the  breast  was  excised. 
In  twenty-six  cases  the  operator  suspicious  of  malignancy  performed 
the  complete  operation  for  cancer.  In  a  few  cases  because  of  a  re- 
tracted nipple  and  dimpled  skin.  In  a  few  others  on  account  of  the 
complicated  gross  pathology  (Fig.  340)  multiple  minute  cysts  and 
dilated  ducts.     In  a  few  cases  after  microscopic  study. 

In  42  cases,  clinically,  there  were  multiple  tumors,  and  at  operation 
multiple  cysts  were  found  (Fig.  340).     In  10  of  these  cases  the  breast 


LESIONS  OF  THE  FEMALE  BREAST 


609 


was  preserved,  in  19  cases  one,  and  in  13  both  breasts  were  removed. 
The  microscopic  study  of  these  breasts  with  multiple  cysts  differs 
from  the  breast  containing  a  single  cyst  only  in  the  number  of  simple 
cysts,  and  as  a  rule  the  chronic  cystic  mastitis  is  present  to  a  larger 
extent. 

During  the  same  period  of  25  years  we  have  recorded  25  cases 
of  cancer  in  chronic  cystic  mastitis  or  senile  parenchymatous  hyper- 
trophy.    In  none  of  these  cases  was  there  found  a  fully  developed  area 


Fig.  341. — Early  adenocarcinoma  in  adenomatous  areas. 
Pathol.  No.  13204. — Operation  in  191 2,  exploration  followed  by  the  complete  operation 
jor  cancer.     White,  female,  aged  49;  intermittent  retraction  of  the  nipple  18  months;  pain 
and  tumor  four  months.     Two  years  later  excision  of  other  breast  for  similar  condition. 
1916,  four  years,  well. 


of  scirrhous  or  medullary  carcinoma.  In  this  group  there  is  only  one 
patient  dead  of  cancer,  and  in  this  case  we  find  after  serial  sections  an 
area  of  fully  developed  cancer  about  which  no  pathologists  would 
disagree.  The  other  cases  have  all  been  submitted  to  a  number  of 
consulting  pathologists,  and  not  in  a  single  case  is  there  uniform 
agreement. 

It  is  important  to  note,  however,  that  in  every  one  of  these  cases  the 
breast  was  completely  removed  as  shown  in  Fig.  339.  In  four  cases  the 
excision  of  the  breast  was  the  extent  of  the  operation,  in  five  cases  the 

39 


6io 


REGIONAL    SURGERY 


operation  consisted  first  of  the  removal  of  the  tumor  followed  after  an 
interval  by  the  complete  operation  for  cancer. 


Fig.  342. — Adenocarcinoma  in  adenomatous  areas. 
Pathol.  No.  11799. — Operation  in  1911,  excision  of  tumor;  a  few  weeks  later  complete 
operation  for  cancer.     1916,  five  years,  well. 

White,  femcale,  aged  26,  tumor  two  months.     The  tumor  in  the  gross  resembled  Fig.  337. 


Fig.  343. — Cancer  (?)  in  chronic  cystic  mastitis.     Photograph  of  the  section  of  breast 

removed. 
Pathol.  No.  5221. — Operation  in  1904,  excision  of  breast  only.     1916,  12  years  well. 
White,  female,  aged  46;  enlargement  of  one  quadrant  of  the  breast  four  months.     For 
microscopic  appearance  see  Fig.  344. 


It  seems  to  me  that  the  key  to  the  situation  is  the  one  case  in  which 
there  was  a  death  from  cancer  in  spite  of  the  complete  operation.     In 


LESIONS    OF    THE    FEMALE   BREAST 


6ii 


all  breasts  which  show  the  type  of  chronic  cystic  mastitis  as  illustrated 
in  Fig.  339  the  complete  operation  for  cancer  is  the  safer  procedure. 

Microscopic  Study. — When  these  cases  were  studied  under  the 
microscope  histological  pictures  were  found  never  observed  in  the  170 
cases  of  chronic  cystic  mastitis  with  large  cysts,  and  50  cases  of  chronic 
cystic  mastitis  without  large  cysts.  Figs.  341  and  342  have  been  con- 
sidered adenocarcinoma  beginning  in  adenomatous  areas  and  should  be 
compared  with  Figs.  312,  313,  314,  331  and  333.  Figs.  343  and  344  have 
been  looked  upon  as  adenocarcinoma  in  adenocystic  areas  and  should 
be  compared  with  Figs.  317,  328  and  329. 


FiG.i'344. — Adenocarcinoma  on  adenocystic  area.     Compare  with  Figs.  317,  328  and 
329.     For  gross  appearance  and  history  see  Fig.  343. 

Duct  Carcinoma  {Comedo  Adenocarcinoma).- — At  the  exploratory 
incision  this  has  such  a  distinct  gross  appearance  that  one  should  never 
fail  to  recognize  it.  It  may  appear  as  a  circumscribed,  but  not  encap- 
sulated tumor  similar  to  Fig.  337,  or  as  a  diffuse  area  involving  a  quad- 
rant, hemisphere  or  the  entire  breast,  as  in  Fig.  345,  From  the  cut 
surface  of  the  tumor,  no  matter  what  its  size,  one  can  express  worm-like 
necrotic  tissue  after  which  there  is  left  a  little  space,  as  shown  in  Fig,  345. 
Microscopically  (Fig.  346),  it  is  as  characteristic  as  in  the  gross,  and 
easily  distinguished  from  the  benign  duct  adenoma  (Fig.  319).     I  saw 


6l2  REGIONAL   SURGERY 

and  described,  this  tumor  first  in  1893,  and  up  to  the  present  time  I 
have  records  of  23  cases,  in  which  the  tumor,  in  the  gross  and  micro- 
scopic appearance  resembled  Figs.  345  and  346.  In  not  one  of  these 
cases  has  there  been  metastasis  to  the  glands  in  the  axilla,  nor  have  any 
of  the  patients  died  of  cancer.  The  tumor  is  often  associated  with  re- 
traction of  the  nipple,  ulceration,  and  even  the  development  of  a 
fungus. 

Duct  cancer  resembles  chronic  cystic  mastitis  in  that  there  may  be 
a  circumscribed  area,  or  a  diffuse  change  in  part  of,  or  in  the  entire 
breast.  Comedones  and  duct  adenomas  are  not  infrequently  observed 
in  small  areas  in  chronic  cystic  mastitis. 


Fig.  345. — Duct  cancer,  involving  the  entire  breast  (comedo  adenocarcinoma).     Section 

of  breast  through  nipple. 
Pathol.  No.  15427. — Operation  in  1914,  exploratory  followed  by  complete  for  cancer. 
White,  female,  aged  38;  tumor  2  years,  associated  with  slight  discharge  of  grumous  material 
from  nipple  and  pain.     19 16,  well. 

In  a  larger  number  of  cases  this  duct  carcinoma  has  been  present  in 
small  or  large  areas  of  a  fully  developed  scirrhous  or  medullary  car- 
cinoma. In  the  latter  group  the  glands  often  show  metastasis,  and 
the  probability  of  a  cure  is  identical  with  that  in  the  fully  developed 
scirrhous  or  medullary  carcinoma. 

Adenocarcinoma  in  Cystic  Adenoma. — Cystic  adenoma  (Fig.  327) 
differs  from  chronic  cystic  mastitis  (Fig.  339)  only  in  its  encapsulation. 
Our  12  cases  diagnosed  cancer  in  cystic  adenoma  were  not  encapsulated 
tumors,  but  circumscribed,  resembling  Fig.  337.  In  many  of  the  cases 
the  tumors  were  of  long  duration — 5  to  25  years,  with  a  history  of 


LESIONS    OF   THE    FEMALE  BREAST  613 

recent  growth.  In  a  few  the  tumor  had  been  observed  less  than  a  year. 
The  ages  of  the  patients  varied  from  twenty-nine  to  seventy-seven. 
Three  cases  were  observed  during  lactation.  A  few  of  these  cases 
undoubtedly  were  cancers,  because  the  patients  died  of  cancer.  In 
these  cases  there  were  distinct  areas  of  scirrhousor  medullary  carcinoma. 


m' 


Fig.  346. — Duct  cancer  (comedo  adenocarcinoma). 
Pathol.  No.  2815. — Operation  in  1899,  complete  for  cancer  on  both  breasts.     White, 
female,  aged  52;  tumor  of  one  breast  two  years;  recent  ulceration  with  fungus  formation, 
Small  tumor  in  other  breast.    The  patient  lived  14  years  and  died  of  causes  other  than  cancer. 

Microscopically,  they  show  the  same  histological  picture,  as  already 
noted  of  cancer  in  chronic  cystic  mastitis  (Figs.  341,  342  and  344). 

It  will  always  be  safer  when  you  meet  a  circumscribed  tumor  as 
pictured  in  Fig.  337  to  treat  it  as  malignant,  even  if  it  has  a  cystic 
appearance  as  shown  in  the  tumor  in  Fig.  327. 


6i4 


REGIONAL   SURGERY 


Fig.  347 . — Colloid  cancer.     Circumscribed  tumor  involving  a  large  portion  of  the  breast 

beneath  the  nipple,  showing  infiltration  of  the  breast  beyond  the  tumor. 
Pathol.  No.  9733. — Complete  operation  for  cancer  in  1909.     White,  female,  aged  31, 

tumor  two  years. 


Fig.  348. — Colloid  cancer. 

Pathol.  No.  4874. — Complete  operation  for  cancer  in  1903.     White,  female,  aged  43, 

tumor  nine  months.     1916,  13  years,  well. 


LESIONS    OF    THE    FEMALE   BREAST  6l5 

Colloid  Adenocarcinoma. — When  explored,  the  gross  appearance  of 
this  tumor  (Fig.  347)  is  sufficiently  characteristic  to  allow  a  positive 
diagnosis  and  indicate  the  immediate  complete  operation  for  cancer.  I 
have  received  a  number  of  colloid  cancers  in  the  laboratory  for  diagnosis 
the  operator  having  unfortunately  removed  the  tumor  alone.  In  every 
instance  there  has  either  been  recurrence,  or  death  from  cancer  in  spite 
of  a  second  operation.  The  microscopic  appearance  is  entirely  different 
from  any  other  lesion  of  the  breast  (Fig.  348). 

In  the  past  few  days  I  have  found  in  a  young  colloid  cancer,  areas  of 
intracanalicular  myxoma  (Fig.  335)  suggesting  that  this  cancer  may  origi- 
nate in  this  common  benign  tumor.  But  our  evidence  at  the  present 
time  is  too  slight  to  reach  a  positive  conclusion. 


Fig.  349. — Scirrhous  carcinoma.  A  somewhat  circumscribed  area,  but  showing  distinct 
dots  and  lines  in  contrast  with  Fig.  337.  Note  also  the  slight  retraction  of  the  nipple.  The 
surrounding  breast  is  chiefly  fat.  There  is  a  little  stroma  between  the  tumor  and  the 
nipple.     There  is  no  gross  evidence  of  chronic  cystic  mastitis. 

Pathol.  No.  18840. — Recent  case.     For  microscopic  appearance  see  Fig.  308. 

Malignant  Papillomatous  Cyst. — In  my  experience  with  25  cases 
the  malignant  papillomatous  cyst  has  shown  clinical  evidence  of  its 
malignancy  by  changes  in  the  skin  or  nipple  in  over  85  per  cent, 
of  the  cases.  The  probabilities  are,  therefore,  when  you  explore  a 
papillomatous  cyst,  that  the  tumor  is  still  benign.  The  malignant 
papilloma  has  lost  its  papillomatous  form  and  looks  entirely  different 
from  the  papilloma  in  Fig.  321.  It  has  assumed  a  fungous  appearance. 
In  addition,  the  cyst  wall  at  the  base,  and  the  breast  beyond  are 
infiltrated. 

When  one  explores  a  breast  tumor  and  finds  a  cyst  partially,  or 
completely,  filled  with  a  distinct  papilloma,  and  at  the  base  of  the 
papilloma  there  is  a  distinct  cyst  wall  separating  the  papilloma  from 
the  breast,  and  the  breast  beyond  looks  normal,  excision  of  the  cyst 


6l6  REGIONAL   SURGERY 

with  a  zone  of  breast  is  a  justifiable  operation.  In  all  other  cases  it 
is  safer  to  perform  the  complete  operation  for  cancer. 

Scirrhous  Carcinoma. — Until  recently  (Fig.  337)  I  felt  that  one  should 
always  recognize  a  scirrhous  carcinoma  at  an  exploratory  incision 
by  its  hardness,  by  its  gritty  sensation  to  the  knife,  by  its  peculiar 
markings  in  fine  dots  and  lines  (Fig.  349). 

In  my  past  experience  I  had  observed  scirrhous  cancer  as  a  dis- 
tinctly circumscribed  area  and  as  an  infiltrating  zone  from  the  size 
of  the  end  of  the  little  finger  up  to  a  tumor  involving  the  entire  breast. 
In  every  instance  the  gross  appearance  was  the  same  and  the  diagnosis 
confirmed  by  the  microscopic  section. 

But  now  that  women  are  seeking  advice  earlier  we  are  seeing 
apparently  for  the  first  time  a  new  group  of  tumors  (see  Fig.  337). 
Frozen  sections  will  probably  not  help  us  in  the  differential  diagnosis 
(see  Fig.  338). 

The  circumscribed  and  infiltrating  areas  which  resemble  scirrhous 
carcinoma  should  at  the  present  time  be  treated  as  malignant.  I  am 
confident  that  if  we  attempt  to  differentiate  and  be  conservative  in 
the  smaller  group  too  many  mistakes  will  be  made  in  performing  in- 
complete operations  for  cancer.  Apparently  the  circumscribed  area 
is  a  precancerous  lesion,  and  it  will  probably  be  safer  never  to  be  con- 
servative in  removing  the  lesion  only,  at  least  until  we  have  had  a 
much  larger  experience. 

Cancer  in  Old  Mastitis. — On  page  607  I  have  referred  to  the 
possibility  of  a  carcinoma  developing  in  the  residual  scar  after  mastitis. 
In  all  of  our  cases  the  patients  have  been  aware  of  the  area  of  induration 
after  mastitis  from  periods  of  15  to  30  years.  They  have  come  under 
observation  only  after  observing  recent  growth,  with  further  changes 
in  the  skin  and  nipple.  Recently  I  have  had  the  opportunity  to 
excise  a  chronic  mastitis  scar  in  the  benign  state.  The  cancer  in  all 
of  these  cases  has  always  been  of  the  scirrhous  type,  but  in  every 
instance  we  have  been  able  to  recognize  with  the  microscope  (Fig.  308) 
the  remains  of  the  old  ducts  surrounded  by  a  zone  of  chronic 
inflammatory  tissue. 

Medullary  Carcinoma. — This  tumor,  when  small  and  clinically 
benign,  is  practically  always  a  somewhat  circumscribed  area.  I  can 
imagine,  but  I  have  never  seen,  an  encapsulated  medullary  carcinoma. 
It  would  probably  then  suggest  an  intracanalicular  myxoma,  and  the 
frozen  section  would  differentiate  it.  The  medullary  carcinoma,  in 
contrast  with  scirrhus,  is  friable,  little  pieces  can  easily  be  picked  out 


LESIONS    OF   THE    FEMALE   BREAST 


617 


Fig.  350. — Hemorrhagic  medullary  carcinoma.     Photograph  of  section  through    the 

breast,  showing  circumscribed,  cellular,  hemorrhagic  tumor. 

The  breast  is  rather  fatty  and  fibrous,  with  no  evidence  of  chronic  cystic  mastitis. 


Fig.  351. — A  tumor  of  the  breast  clinically  malignant.     The  nipple  is  retracted,  the  skin 
dimpled.     The  center  of  the  breast  is  occupied  by  an  indurated  mass. 
Pathol.  No.  2392.- — Complete  operation  for  cancer  in  1898.     No  metastasis  to    axilla. 
1916,  18  years  well.     White,  female,  aged  51;  tumor  two  years  and  five  months.     Discharge 
from  nipple  18  months. 

The  removed  breast  was  the  seat  of  an  infiltrating  scirrhus.     No  evidence  of  the  paren- 
chyma of  the  breast  remaining. 


6l8  REGIONAL    SURGERY 

with  the  knife.     Now  and  then  these  tumors  are  very  hemorrhagic 
(Fig.  350)- 

Sarcoma. — Metastatic  sarcoma  is  so  infrequent  in  the  breast  that 
it  need  not  be  considered  here.  I  have  seen  one  case  among  almost 
1800  breast  lesions.  A  correct  diagnosis  would  not  help,  nor  an  in- 
correct one  harm  the  patient.  In  this  case  the  tumors  were  multiple^ 
felt  distinctly  benign  and  appeared  a  few  months  after  an  operation 
for  a  malignant  tumor  of  the  ovary. 

The  most  common  sarcoma  of  the  breast  is  a  secondary  develop- 
ment in  an  intracanalicular  myxoma.  The  tumor  as  a  rule  is  large, 
usually  occupying  more  than  half  of  the  breast.  The  best  rule  is 
to  treat  all  large  intracanalicular  myxomas  on  the  diagnosis  of  sarcoma. 
The  differential  diagnosis  from  the  large  aberrant  fibroadenoma  can 
be  made  at  the  exploratory  incision.  The  gross  appearance  of  a 
fibroadenoma  (see  Fig.  336)  should  easily  be  difi'erentiated  from  the 
intracanalicular  myxoma. 

The  fibroadenoma  as  a  rule  is  in  younger  women,  and  the  larger 
aberrant  tumor  is  always  outside  the  breast.  Apparently,  however, 
difl'erential  diagnosis  between  these  two  forms  has  been  difficult. 
I  have  mentioned  this  before  fpage  604). 

The  indigenous  sarcoma  of  various  types  and  mixed  tumors  con- 
taining cartilage  and  myxomatous  tissue  offer  no  difficulty  at  all 
at  the  exploratory  incision;  although  circumscribed,  their  appearance 
will  never  be  confused  with  that  of  any  benign  breast  tumor. 

Clinically  Malignant  Tumors  (Fig.  351). — If  we  define  retraction  of 
the  nipple,  dimpling  and  other  changes  of  the  skin  already  described, 
and  ulceration  of  the  nipple  as  the  usual  signs  of  cancer,  we  have 
therefore  the  description  of  a  clinically  malignant  tumor  of  the  breast. 
All  of  these  signs  have  been  carefully  described  (page  576).  We 
must  also  remember  that  these  symptoms  may  now  and  then  be  as- 
sociated with  benign  breast  lesions.  However,  except  in  the  few 
instances  already  defined,  it  seems  safer  to  perform  the  complete 
operation  for  cancer  without  an  exploratory  incision. 

Operation.— iVo  'woman  should  he  subjected  to  an  operation  for  a 
breast  lesion,  except  for  a  lactation  mastitis  abscess,  unless  the  surgeon 
is  prepared  to  make  the  diagnosis  at  the  exploratory  incision  and  to 
perform  the  complete  operation  for  cancer  if  indicated. 

Now  that  w^omen  are  seeking  advice  earHer  I  am  inclined  to  think 
that  a  most  painstaking  chnical  history  and  examination  along  the  lines 


LESIONS    OF   THE    FEMALE   BREAST  619 

laid  down  in  the  beginning  of  this  article  will  be  most  helpful,  and  more 
so  than  in  the  past. 

By  this  we  must  exclude  a  group  (getting  larger  each  day)  in  which 
operation  is  not  indicated. 

When  the  palpable  breast  lump  is  clinically  benign  the  operation 
begins  with  an  exploratory  incision. 

Exploratory  Incision. — There  is  no  objection  to  performing  this 
under  novocaine,  with  or  without  gas.  The  incision  should  be  made 
from  the  areola  out  and  over  the  tumor,  pushing  the  breast  and  tumor 
toward  the  knife.  Divide  the  skin  and  subcutaneous  fat.  Clamp 
the  bleeding  points.  These  clamps  will  do  for  retractors.  Inspect 
the  exposed  breast  tissue.  Have  a  dry  field.  Often  the  blue  dome  of 
the  simple  benign  cyst  is  exposed,  and  not  infrequently  in  malignant 
tumors  one  can  see  and  feel  the  infiltrated  breast  tissue  at  this  point 
of  the  incision. 

When  the  exposed  breast  looks  and  feels  normal,  cut  through  it, 
still  pushing  the  tumor  toward  the  knife;  clamp  the  bleeding  points; 
inspect  the  breast  tissure  carefully  as  it  is  -divided.  It  is  surprising 
how  rapidly  the  benign  cyst  or  encapsulated  benign  tumor  is  exposed 
to  view,  while  in  the  malignant  tumor  one  often  feels  that  they  are  not 
being  exposed  as  rapidly  as  expected. 

This  is  explained  by  the  fact  that,  in  the  benign  cystic  and  solid 
tumors,  the  zone  of  breast  is  practically  normal,  and  one  palpates  the 
tumor  more  easily  through  the  breast  tissue,  while  in  the  malignant 
tumor  a  very  small  area  may  feel  so  much  larger  than  it  really  is,  that 
when  you  cut  into  the  palpable  mass,  you  do  not  expose  the  real  disease, 
because  it  is  in  the  center  of  it. 

In  my  own  experience  I  have  never  missed  a  benign  tumor  at  the 
exploratory  incision,  no  matter  how  small.  But  on  a  few  occasions 
I  have  had  the  greatest  difficulty  in  isolating  the  very  small  scirrhous 
cancer,  and  a  number  of  cases  have  come  to  me  in  which  the  carcinoma 
had  been  missed  at  the  exploratory  incision.  Difficulty,  therefore,  in 
readily  exposing  the  palpable  tumor  at  the  exploratory  incision  is  sug- 
gestive of  malignancy. 

The  moment  you  find  signs  of  malignancy,  disinfect  the  wound  with 
pure  carbolic  acid  followed  by  alcohol,  and  then  use  the  cautery  if  you 
desire.  I  have  tried  the  cautery  for  exploration  of  breast  tumors  and 
have  so  far  found  it  unsatisfactory.  Again,  one  can  disinfect  more 
rapidly  with  carbolic  and  alcohol  than  with  the  cautery. 


620  REGIONAL    SURGERY 

Having  disinfected  the  supposed  malignant  tumor,  close  the  skin 
wound  and  proceed  with  the  complete  operation  for  cancer. 

Some  surgeons  QUt  out  a  piece  for  frozen  section,  others  cut  out  the 
entire  tumor  for  inspection  and  frozen  section.  This  has  not  been  the 
practice  nor  the  teaching  of  Dr.  Halsted  and  I  have  no  regrets,  because 
I  have  always  followed  his  precept  and  all  my  accumulated  evidence  is 
in  favor  of  it. 

It  is  surprising  how  rapidly  one  can  differentiate  at  this  exploratory 
incision.  The  benign  cyst  and  the  encapsulated  tumor  are  recognized 
at  once,  and  for  these  tumors  a  local  operation  is  usually  justifiable. 
In  the  other  groups  it  is  safer  to  perform  the  complete  operation  for 
cancer  anyway.  Of  course,  there  are  some  exceptions.  To  recognize 
these  exceptions  requires  great  experience.  If  the  majority  follow 
the  rule  as  stated,  there  should  be  no  incomplete  operations  for  cancer. 
There  will  be  some  complete  operations  for  benign  lesions.  Up  until 
the  last  few  years  in  my  observation  this  was  done  in  about  lo  per  cent. 
of  the  benign  lesions.  In  the  last  three  years  this  has  increased  in 
experienced  hands  to  15  per  cent. 

An  incomplete  operation  for  cancer  of  the  breast  offers  the  patient 
little  more  probability  of  a  cure  than  if  there  had  been  no  operation 
at  all.  Operations  in  two  stages  do  not  compare  in  the  results  with 
one-stage  operations. 

Removal  of  Tumor. — Having  exposed  the  benign  cyst  or  the  encap- 
sulated benign  tumor,  remove  it  with  a  zone  of  breast  through  the 
incision  made  for  exploration.  Nothing  is  gained  by  enucleation.  If 
one  attempts  to  enucleate  one  may  leave  behind  pieces  of  tumor  tissue 
which  may  become  foci  of  second  growth.  I  have  observed  such  recur- 
rences after  enucleation  chiefly  in  mixed  tumors  of  the  parotid,  but 
recently  a  number  have  come  under  my  observation  in  which  the  tumor 
had  been  enucleated  from  the  breast. 

It  is  simpler  to  remove  these  tumors  by  cutting  through  the  breast. 
It  also  gives  one  the  opportunity  to  see  the  breast  tissue. 

Closure  of  the  Woimd. — The  breast  tissue  should  be  approximated 
with  interrupted,  rapidly  absorbing  catgut,  as  a  rule  in  three  layers. 
The  subcutaneous  fat  and  the  skin  are  approximated  with  fine  silk. 
Buried  silk  and  chromic  catgut  in  breast  tissue  may  give  rise  to  a  chronic 
mastitis  resulting  in  a  palpable  tumor  which  may  be  very  difi&cult  to 
distinguish  from  a  malignant  one. 

The  breast  wound  should  be  closed  most  carefully,  as  hematoma 
usually  results  in  a  breakdown. 


LESIONS    or   THE    FEMALE   BREAST  62 1 

The  dressing  on  the  breast  should  be  snug,  fixed  with  adhesive  straps 
and  reinforced  with  a  bandage. 

When  such  details  have  been  followed,  the  wounds  heal,  the  patient 
and  the  surgeon  are  not  worried  by  scar-tissue  tumors  or  scar  pain,  and 
the  subsequent  function  of  the  breast  is  never  impaired.  I  have 
removed  at  one  sitting  three  tumors  from  one  breast  and  have  operated 
twice  on  the  same  breast  for  a  benign  tumor  without  sacrificing  the 
breast,  or  leaving  any  mutilation. 

I  have  observed  a  few  examples  where  after  the  removal  of  a  benign 
breast  tumor  a  huge  defect  could  be  seen  and  felt  in  the  breast.  The 
deformity  is  really  more  unsightly  than  the  removal  of  the  breast,  and, 
of  course,  it  is  avoidable. 

In  my  experience  it  is  perfectly  justifiable  to  confine  the  operation  to 
the  removal  of  the  tumor  only  in  simple  cysts,  papillomatous  cysts, 
galactocele,  cystic  adenoma,  fibroadenoma  and  small  intracanalicular 
myxoma — that  is  the  typical  benign  cyst  and  encapsulated  benign 
tumors.  It  is  justifiable  to  remove  one  or  more  of  such  tumors  leaving 
the  breast.  I  would  be  more  inclined  to  remove  the  entire  breast  in 
multiple  cystic  adenomas  than  in  any  other  form  of  multiple  benign 
lesion. 

In  young  girls  one  may  palpate  what  seems  to  be  a  distinct  tumor 
as  a  rule  in  the  axillary  quadrant.  Yet,  when  one  cuts  down  upon 
such  an  area  there  is  no  cyst,  no  encapsulated  tumor,  simply  a  zone  of 
breast  tissue  to  be  distinguished  from  the  surrounding  white  breast 
tissue  by  numerous  pink,  elevated  dots.  The  youth  of  the  patient 
helps  in  the  differentiation.  Microscopically,  we  find  adenomatous 
hypertrophy  (Fig.  312).  Especially  in  young  girls  this  pecuHar  lesion 
should  be  recognized,  because  excision  of  this  zone  is  sufficient.  The 
probabiHties  are  that  operation  is  not  indicated  at  all,  but  when  one 
feels  a  distinct  tumor,  we  know  it  is  safer  to  operate.  But  we  must 
also  recollect  that  we  may  not  find  a  distinct  tumor,  but  just  an  area 
of  such  hypertrophied  breast. 

The  same  condition  may  be  present  in  older  women  at  the  cancer 
age;  we  feel  an  area  of  induration  or  even  a  distinct  tumor,  which  as  a 
rule  is  painful  and  tender.  However,  when  we  cut  down  upon  this 
zone  we  are  disappointed — there  is  neither  a  cyst,  nor  an  encapsulated 
tumor,  nor  really  any  distinct  disease.  My  records  show  a  number  of 
such  cases  in  which  the  surgeon  has  been  able  to  recognize  the  be- 
nignity of  this  lesion  and  has  had  the  courage  of  his  conviction.  None 
of  these  patients  lost  the  breast,  nor  have  any  of  them  suffered  from 


62  2  REGIONAL   SURGERY 

this  wise  conservatism.  Unfortunately,  however,  in  a  larger  group 
the  operators  have  either  been  unable  to  make  the  diagnosis,  or  have 
lacked  conviction.  The  operation  has  either  been  complete  removal  of 
the  breast  or  that  for  cancer.     Not  one  of  these  patients  has  died  of  cancer. 

To  the  less  experienced  perhaps  a  frozen  section  would  be  very 
helpful  in  differentiating  this  non-encapsulated  zone  of  adenomatous 
hypertrophy.  Next  to  intracanalicular  myxoma  it  is  the  easiest  to 
recognize  from  its  microscopic  appearance  (Fig.  312). 

If  one  can  recognize  the  chronic  lactation  mastitis  with  abscess, 
excision  of  the  zone,  if  the  lesion  is  single,  is  sufl&cient.  My  figures 
show  that  in  at  least  30  per  cent,  of  the  cases  the  chronic  lactation 
mastitis  has  been  treated  on  a  diagnosis  of  malignancy. 

It  appears  to  be  the  uniform  rule  in  tuberculosis  of  the  breast 
to  remove  the  entire  breast,  but  in  the  beginning  the  tuberculosis 
may  be  a  single  focus,  and  I  am  confident  that  the  time  is  coming 
when  these  younger  women  will  not  be  unnecessarily  mutilated  for  a 
small  focus  of  tuberculosis  in  one  breast. 

Excision  of  Breast. — In  some  cases  we  can  proceed  with  excision 
of  the  breast  without  an  exploratory  incision  on  account  of  the  ability 
to  make  a  pretty  definite  diagnosis  of  a  benign  lesion  involving  the 
entire  breast. 

In  diffuse  virginal  and  gravidity  hypertrophy  in  which  the  en- 
largement has  reached  a  certain  stage  one  can  proceed  at  once  with  the 
removal  of  one  or  both  breasts.  In  mastitis  with  multiple  sinuses  and 
abscesses  this  operation  is  possible  without  an  exploratory  incision. 
In  multiple  tumors  in  women  over  30  years  of  age  when  the  breast 
is  riddled  with  shot-like  areas,  the  majority  of  surgeons  excise  the 
breast.  This  is  also  true  when  the  sinus,  induration  and  the  history 
suggest  tuberculosis. 

In  my  experience  the  deliberate  excision  of  one  breast  on  the 
positive  clinical  diagnosis  of  a  benign  lesion  is,  with  rare  exceptions,  a 
procedure  fraught  with  danger;  of  mutilation  for  a  benign  lesion  on 
one  hand,  or  of  an  incomplete  operation  for  cancer  on  the  other.  For 
all  single  palpable  areas,  and  even  for  cases  in  which  the  breast  shows 
multiple  areas,  it  is  on  the  whole  safer  to  explore.  The  excision  of  the 
breast  rests  upon  the  character  of  the  local  lesion,  the  pathology  of 
the  surrounding  breast,  the  age  of  the  patient,  and,  to  some  extent, 
the  wishes  of  the  patient. 

I  have  already  described  the  local  lesion  in  which  it  seems  safe  to 
confine  our  operation  to  the  excision  of  the  tumor  only. 


LESIONS    OF    THE   FEMALE   BREAST  623 

A  number  of  patients,  especially  those  who  have  nursed  children, 
prefer  to  have  the  breast  removed  rather  than  run  the  risk  of  second 
operations.  In  all  benign  single  lesions  there  is  always  the  possibility 
of  multiple  foci  which  later  grow. 

Older  women  with  huge,  fatty  breasts  are  probably  protected  by 
the  complete  removal  of  the  breast,  because  in  breasts  of  this  kind 
it  is  difficult  to  exclude  other  lesions,  and  when  cancer  begins  it  spreads 
rapidly. 

When  the  chronic  cystic  mastitis  exposed  in  removing  the  single 
tumor  is  very  extensive  in  the  breast,  patients  will  probably  be  saved 
second  operations  by  the  primary  removal  of  the.  breast.  This  is 
such  an  easy  condition  to  recognize  that  mistakes  are  rarely  made,  but 
many  breasts  are  unnecessarily  removed  for  this  condition  in  its  earlier 
stages. 

In  chronic  cystic  mastitis  without  large  cysts,  except  in  the  early 
adenomatous  stage,  it  is  my  opinion  that  it  is  safer  to  remove  the 
entire  breast.  If  one  can  recognize  the  chronic  lactation  mastitis 
and  the  multiple  galactoceles,  excision  of  the  breast  is  sufficient,  but 
in  my  experience  the  majority  of  surgeons  have  performed  the  com- 
plete operation  for  cancer  when  this  disease  was  exposed  at  the 
exploration. 

In  every  instance  the  breast  alter  removal  should  be  cut  up  in 
serial  sections  with  a  large  amputating  knife  and  studied  for  a  possible 
area  of  cancer.  Frozen  sections  can  be  made  and  in  some  instances 
may  be  helpful.  In  the  presence  of  cancer  the  complete  operation 
should  follow  at  once. 

When  for  any  reason  I  have  decided  to  excise  the  breast  I  always, 
by  a  most  painstaking  dissection,  attempt  to  protect  the  individual 
by  the  complete  removal  of  all  breast  tissue,  because  theoretically,  any 
bit  of  breast  tissue  left  behind  might  act  as  a  focus  for  a  subsequent 
benign  or  malignant  tumor. 

The  complete  excision  of  the  breast  is,  on  the  whole,  rather  more 
difficult  that  the  complete  operation  for  cancer,  because  more  skin  is 
saved,  and  the  dissection  of  this  skin  from  the  breast,  to  be  properly 
done,  is  a  delicate  procedure,  and  very  bloody,  unless  numerous  bleeding 
points  are  clamped. 

The  nipple  and  areola  are  always  removed.  The  area  of  skin 
beyond  this  varies  with  the  size  of  the  breast :  the  larger  the  breast  the 
larger  the  area  of  skin;  the  larger  the  mass  removed,  the  smaller  the 
area  of  skin  necessary  to  cover  the  defect. 


624  REGIONAL   SURGERY 

The  incision  should  begin  over  the  rib  near  the  rectus  muscle  in 
about  the  parasternal  line  and  curve  upward  and  outward  to  a  point 
where  the  breast  and  pectoralis  major  muscle  meet  in  the  axilla;  a 
second  curved  incision  below  encircles  the  nipple,  the  areola,  an  area  of 
skin  outlined  for  removal.  These  skin  flaps  should  be  dissected  prac- 
tically clean  of  subcutaneous  fat  over  the  breast  tissue.  It  is  simpler  to 
dissect  the  upper  flap  first  until  the  pectoralis  major,  and  sometimes  the 
rectus  muscle,  is  exposed.  It  facilitates  the  dissection  to  remove  the 
pectoral  fascia  with  the  breast.  The  dissection  proceeds  until  the  axil- 
lary fat  is  exposed.  Now  the  skin  fat  on  the  outer  side  is  dissected  until 
the  latissimus  dorsi  and  serratus  magnus  muscles  are  exposed.  This 
mass  is  then  lifted  up,  and  the  connection  with  the  chest  wall  divided 
from  the  lower  point  up  toward  the  axilla.  In  this  way  the  fat  and 
fascia  of  the  space  below  the  axilla  on  the  chest  wall  are  removed  with 
the  breast,  and  the  dissection  is  thus  clean  and  complete  as  for  cancer 
up  to  the  base  of  the  axilla. 

Up  to  this  point  the  dissection  is  just  as  complete  as  in  the  operation 
for  cancer,  except  that  the  area  of  skin  is  a  little  smaller  and  the  pectoralis 
major  muscle  is  not  removed. 

In  the  opinion  of  the  majority  the  removal  of  the  pectoral  muscle 
is  made  to  allow  a  better  exposure  of  the  axilla,  and,  therefore,  a  more 
thorough  dissection. 

If  the  operation  for  the  removal  of  the  breast  proceeds  along  this 
line  up  to  this  point,  we  really  have  nothing  more  to  do,  if  early  cancer 
is  demonstrated,  than  to  remove  the  pectoral  muscle  and  complete  the 
axillary  dissection. 

It  is  my  rule,  in  the  majority  of  cases  to  clamp  the  axillary  attach- 
ments with  the  broad  ligament  clamp  and  make  serial  sections  of  the 
breast,  searching  for  cancer.  In  two  instances  cancer  was  demonstrated, 
and  the  operation  for  cancer  immediately  followed.  In  one  of  these 
cases  it  is  more  than  six  years  since  this  was  done,  and  there  has  been 
no  recurrence;  the  other  case  is  recent. 

If  the  operator  decides  that  the  breast  condition  is  benign,  the 
vascular  attachments  to  the  axillary  area  are  ligated  and  the  wound  is 
closed. 

It  is  my  habit  to  close  the  wound  with  interrupted  fine  black  silk. 
The  wound  after  the  excision  of  the  breast  usually  fills  with  serum.  I 
am  inclined  to  think  that  this  is  due  to  torn  lymph  vessels,  because  this 
accumulation  is  very  much  less  frequent  after  the  complete  operation 
for  cancer  when  the  skin  wound  is  primarily  closed. 


LESIONS    OF   THE    FEMALE  BREAST  625 

When  the  technique  has  been  good,  I  have  been  unable  to  tell 
whether  it  is  better  to  drain  these  wounds  or  not.  If  you  do  not  drain, 
the  serum  can  be  expressed  after  the  fourth  or  fifth  day.  No  drainage 
will  absolutely  prevent  accumulation,  and  some  of  the  serum  will  have 
to  be  expressed  in  any  event.  These  wounds  require  the  most  careful 
after-dressing  to  prevent  infection,  and  with  each  dressing  the  bandage 
must  be  snug. 

There  is  another — and  very  important — reason  for  the  complete 
removal  of  the  breast  along  these  lines.  My  figures  show  that  some 
cases  diagnosed  adenocarcinoma  have  remained  well  and  free  from 
recurrence  of  the  diseases  from  5  to  i6  years  after  the  operation.  The 
number  of  cases  of  this  early  type  of  disease  will  increase  when 
women  seek  advice  early  after  the  first  appearance  of  the  tumor.  At 
the  present  time  we  are  not  in  a  position  to  do  such  a  restricted  opera- 
tion, if  it  is  our  opinion  that  the  lesion  is  cancer.  However,  if  one  has 
decided  to  remove  the  breast,  let  it  be  done  in  this  more  radical  way 
for  the  benefit  of  the  patient.  There  is  no'  more  mutilation,  or  danger, 
nor  is  the  period  of  convalescence  longer  or  more  uncomfortable;  nor 
are  the  chances  of  a  painful  scar  any  greater. 

Excision  of  Both  Breasts. — I  had  hoped  that  our  long  and  intensive 
study  of  the  pathology  of  breast  lesions  in  relation  to  the  results  after 
the  different  operations  would  throw  some  light  on  cases  in  which  the 
pathology  of  one  breast  would  indicate  the  removal  of  the  other.  But 
at  the  present  time  I  do  not  feel  justified  in  giving  any  rule.  It  seems 
safer  to  apply  to  the  other  breast  the  rules  already  stated. 

The  palpable  lesion,  single  or  multiple,  in  each  breast  is  subjected 
to  the  same  diagnostic  scrutiny. 

If  a  patient  has  a  tumor  in  one  breast,  no  definite  tumor  in  the 
other,  but  multiple  shot-like  nodules  or  areas  of  induration,  it  is  prob- 
ably safer  to  remove  both  breasts,  if  the  first  breast  removed  is  the  seat 
of  chronic  diffuse  mastitis  without  large  cysts,  or  of  multiple  cystic 
adenoma. 

When  both  breasts  are  removed  at  one  or  two  operations,  the 
technique  as  described  should  be  employed  for  each  breast. 

Operation  for  Sarcoma. — When  there  is  a  tumor  involving  almost 
half  or  more  of  the  breast  and  the  skin  over  it  is  not  involved,  the 
chances  are  that  it  is  not  carcinoma,  but  that  it  is  either  a  benign  intra- 
canalicular  myxoma  or  some  form  of  sarcoma.  In  these  cases  the  breast 
will  have  to  be  sacrificed,  and  as  most  of  these  tumors  are  sarcoma,  it 
is  better  to  treat  all  as  sarcoma. 
40 


626  REGIONAL    SURGERY 

The  technique  of  the  operation  is  very  similar  to  that  already  described 
for  the  excision  of  the  breast.  The  area  of  skin  should  be  larger  and 
should  include  all  of  the  skin  covering  the  palpable  tumor.  In  addition^ 
the  pectoral  muscle  beneath  the  breast  and  tumor  should  be  removed. 
Theoretically,  there  is  no  objection  to  performing  the  complete  operation 
for  cancer,  but  it  seems  unnecessary.  In  our  early  cases  of  sarcoma  in 
intracanalicular  myxoma  in  which  the  tumor  and  breast  only  were 
removed,  recurrence  in  the  pectoral  muscle  took  place  in  every  instance. 
Since  we  have  removed  the  muscle  there  have  been  no  recurrences. 
In  a  few  of  these  cases  we  have  also  removed  the  axillary  glands.  These 
did  not  show  metastasis. 

T  the  present  time  we  have  never  saved  a  sarcoma  of  the  breast 
other  than  sarcoma  in  intracanalicular  myxoma.  The  patients  died 
of  metastasis  to  the  lungs. 

Complete  Operation  for  Cancer. — In  this  operation  there  is  re- 
moved an  area  of  skin,  a  wider  area  of  subcutaneous  fat,  the  major 
pectoral  muscle,  except  its  clavicular  bundle;  the  minor  pectoral  muscle 
is  either  removed  or  divided,  and  there  is  a  complete  dissection  of  the 
axillary  tissue  without  injury  to  the  main  vessels  and  nerves. 

The  most  striking  part  of  Halsted's  first  report  was  not  the  per 
cent,  of  ultimate  cures,  because  the  time  of  observation  was  too  short, 
but  the  low  per  cent,  of  local  recurrences  in  the  scar,  and  even  of  re- 
gionary  recurrences  on  the  chest  wall.  The  description  of  the  technique 
of  the  operation  in  Halsted's  first  and  subsequent  reports  may  not  have 
been  entirely  clear,  but  the  operation  as  first  performed  by  him  was 
ideal,  and  all  of  his  students  who  have  followed  his  teaching  will  agree 
that  his  method  was  the  fhrst  truly  complete  operation  for  cancer 
of  the  breast. 

From  a  most  painstaking  study  of  the  local  growth  of  cancer  in 
the  breast  and  from  the  position  of  local  and  regionary  recurrences 
I  am  convinced  that  the  chest-wall  dissection  is  the  most  essential 
feature  of  the  operation.  Now  that  patients  are  seeking  advice 
earlier,  the  complete  axillary  dissection  is  becoming  relatively  less 
important. 

Even  in  small  malignant  tumors  of  the  breast  there  may  be  wide- 
spread dissemination  of  cancer  cells  through  the  channel  of  the  gland 
ducts.  I  am  inclined  to  think  that  this  occurs  before  extensive  lym- 
phatic dissemination  in  the  breast.  For  this  reason,  as  described 
under  excision  of  the  breast,  every  particle  of  breast  tissue  must  be 
removed. 


LESIONS    OF   THE   FEMALE  BREAST  627 

Connective-tissue  rich  in  lymphatics  radiates  between  the  skin 
and  the  breast  beneath,  and  when  cancer  reaches  the  skin,  it  may 
disseminate  rapidly  within  a  considerable  zone  of  skin.  For  the 
reason  in  all  cancers  of  the  breast  with  the  slightest  involvement 
of  the  skin  the  skin  area  removed  should  be  larger,  and  with  the  ex- 
tent of  involvement  of  the  skin  the  larger  and  larger  should  be  the  area 
of  skin  excised. 

One  should  never  see  breast  tissue  during  the  operation,  only  fat, 
fascia  and  muscle. 

In  planning  the  area  of  skin  to  be  removed  the  tumor,  not  the  nipple, 
should  be  its  center.  In  this  zone  of  skin  the  nipple  and  areola  should 
always  be  included.  In  thin  patients  with  little  subcutaneous  fat 
always  take^a  larger  zone  of  skin,  because  in  such  instances  it  is  more 
difficult  to  dissect  the  skin  from  the  breast  than  when  there  is  more 
fat.  It  is  far  better  for  the  inexperienced  to  begin  with  the  excision  of 
a  huge  area  of  skin  and  restrict  this  as  experience  is  gained,  rather  than 
the  reverse. 

Freedom  from  recurrence  in  the  region  of  the  scar  does  not  de- 
pend upon  the  closure  or  the  healing  of  the  wound,  but  upon  the 
extent  of  the  surgeon's  dissection  in  relation  to  the  local  extent  of  the 
disease. 

I  have  had  a  large  opportunity  to  compare  the  results  of  different 
methods  of  operation  and  different  surgeons,  and  I  am  confident 
that  the  large  number  of  the  local  recurrences  is  not  due  to  the  ex- 
tensive local  growth  of  the  cancer  at  the  time  of  the  operation,  but 
to  the  restricted  zone  of  skin  and  subcutaneous  tissue  removed  by  the 
surgeon. 

Skin-grafting  can  be  done  a  week  later  with  little  or  no  anaesthesia 
at  all. 

In  planning  the  operation  always  make  it  a  little  more  extensive 
than  the  local  conditions  seem  to  indicate.  The  surgeon  must  watch 
himself  all  the  time  not  to  ''cut  corners,"  to  remember  that  the  object 
of  this  operation  is  to  make  the  best  attempt  possible  to  get  rid  of  the 
malignant  disease. 

It  does  not  make  much  difference  where  one  begins  or  where  one 
ends  in  this  operation  or  in  what  sequence  the  various  steps  follow 
each  other,  providing  each  step  is  well  executed.  In  the  majority  of 
cases  it  seems  simpler  to  dissect  the  upper  skin  flaps  first,  exposing  the 
pectoralis  major  muscle.  Except  when  the  tumor  is  situated  in  the 
axillary  zone,  it  is  unnecessary  to  prolong  the  incision  down  the  arm. 


628  REGIONAL   SURGERY 

After  exposing  this  muscle  I  prefer  to  make  all  of  the  skin  dissection, 
except  in  the  base  of  the  axilla,  until  muscle  is  exposed.  It  facilitates 
most  of  the  operation  to  prolong  the  incision  down  over  the  rectus. 
This  helps  in  enlarging  the  exposure  of  the  subcutaneous  fat  and  later 
allows  one  to  bring  the  skin  flaps  closer  together. 

Muscle. — The  pectoralis  major  muscle  is  so  divided  that  the 
clavicular  bundle  is  left  undisturbed.  As  the  division  extends  upward 
toward  the  rib,  push  down  the  lymphatic  tissue  and  vessels  which 
lie  between  the  two  muscles.  Then  continue  the  division  of  the 
muscle  along  the  sternum,  clamping  the  intercostals.  Extend  the 
division  down  along  the  sternum  to  the  rectus  and  clean  the  rectus  and 
serratus  magnus  of  all  fat  and  fascia  to  be  removed  with  the  tumor 
mass. 

Now  inspect  the  axilla.  If  no  glands  can  be  felt,  you  know  it 
is  a  favorable  case.  If  glands  are  felt  above  the  acromio-thoracic 
vessels  and  in  the  apex  of  the  axilla,  one  must  resect  a  V-shaped  piece 
of  the  clavicular  bundle  of  the  pectoral  up  to  the  clavicle  and  make 
en  bloc  dissection  of  this  muscle,  the  vessels,  and  all  the  tissue  in  the 
space  between  the  clavicle  and  vessels  in  this  area.  In  favorable 
cases  this  is  unnecessary,  and  the  acromio-thoracic  vessels  can  be  left 
undisturbed  just  as  we  leave  the  supraclavicular  fossa  out  of  the  zone 
of  dissection. 

In  proceeding  with  the  axillary  dissection  I  prefer,  after  inspection, 
to  isolate  the  vessels  and  fat  which  pass  from  the  apex  of  the  axiUa 
down  over  the  minor  into  the  major,  clamp  them  and  burn  through 
with  the  cautery.  This  exposes  the  minor.  The  minor  may  be 
divided  in  favorable  cases,  and  each  half  used  as  a  retractor.  In 
unfavorable  cases  it  should  be  completely  removed.  In  unfavorable 
cases  the  dissection  of  the  acromio-thoracic  area  begins  before  the 
removal  of  the  minor,  as  this  gives  more  room  for  attacking  the  muscle. 
But  in  favorable  cases  when  you  divide  the  minor  this  is  done  first, 
and  the  dissection  is  begun  at  the  apex  of  the  axilla,  first  isolating  the 
subclavian  muscle  over  the  vein. 

I  have  always  followed  the  example  of  Halsted  and  isolated  the 
vessels  separately,  ligating  with  fine  silk. 

One  cleans  everything  from  the  vein  from  the  apex  to  the  arm; 
then  there  is  exposed  the  cavity  between  the  subscapular  muscle 
and  the  chest  wall.  In  making  this  dissection  one  must  use  a  com- 
bination of  blunt  sweeping  with  a  piece  of  gauze  as  well  as  the  knife. 
The  process  of  cleaning  everything,  leaving  only  bare  muscle,  major 


LESIONS    OF   THE   FEMALE   BREAST  629 

vessels  and  nerves,  passes  down  over  the  teres  major  and  latissimus 
dorsi  until  it  strikes  the  subcutaneous  fat  at  the  base  of  the  axilla. 
Having  reached  this  point  one  can  push  the  mass  over  into  the  wound 
and  proceed  with  the  dissection  of  the  skin-flap  over  that  area  not 
included  in  the  first  and  second  step. 

Closure  of  the  Wound. — It  is  better  to  skin-graft  than  to  use  ten- 
sion and  have  sloughing  skin-flaps.  I  agree  with  Halsted  that  swelling 
and  oedema  of  the  arm  are  dependent  chiefly  upon  wound  infection, 
ever  so  slight.  For  this  reason  cover  the  vessels  and  make  a  good  axil- 
lary fornix,  then  close  the  remainder  of  the  wound,  if  you  can,  without 
tension;  if  not,  skin-graft  then  or  later,  according  to  experience. 

In  a  few  cases  where  there  is  no  axillary  flap  on  account  of  the  dis- 
section necessary  to  remove  a  malignant  tumor  in  the  axillary  quadrant, 
one  can  easily  make  a  flap  from  the  posterior  skin  area. 

The  direction  of  the  skin  incision  in  length  is  that  described  for  the 
removal  of  the  breast.  The  area  of  skin  removed  within  this  line  varies 
according  to  the  position  of  the  tumor,  the  position  of  the  breast,  the 
size  of  the  breast,  and  the  thickness  of  the  subcutaneous  fat.  It  is 
impossible,  and  therefore  would  be  futile  to  make  one  type  of  incision 
fit  all  cases. 

Neck. — When  the  highest  axillary  glands  are  involved  and  one  has 
made  the  V-shaped  division  of  the  clavicular  bundle  of  the  major,  and 
the  microscope  shows  these  glands  to  be  involved,  the  complete  dis- 
section of  the  supraclavicular  glands  should  be  done  at  a  second 
operation. 

It  is  quite  true  that  the  chances  of  a  permanent  cure  in  such  cases 
are  not  more  than  about  6  per  cent.  However,  when  this  operation  is 
properly  done  there  is  rarely  local  recurrence,  and  many  patients  whose 
lives  are  not  saved  are  made  more  comfortable,  if  this  dissection  is  done 
at  the  proper  time. 

Supraclavicular  Dissection. — From  about  the  middle  of  the  sterno- 
mastoid  muscle  make  an  incision  down  to  the  junction  of  the  inner  and 
middle  thirds  of  the  clavicle  to  join  another  incision  which  runs  along 
the  clavicle.  Reflect  the  two  flaps  outlined  by  the  above  cuts.  Expose 
and  clean  the  sterno-mastoid  down  to  the  clavicle.  Isolate  and  ligate 
the  external  jugular  vein.  Beginning  high  up,  dissect  all  fatty  tissue 
from  the  internal  jugular  vein  downward  to  within  i  or  2  cm. 
of  the  apex  of  the  triangular  exposed  area.  From  without  inward 
clear  the  clavicle  and  subclavian  vessels;  by  pulling  on  the  mobilized 
mass  of  tissue  the  important  dissection  between  the  internal  jugular 


630  REGIOXAL   SURGERY 

and  the  subcla\'ian  veins  is  completed.  Lift  the  mobihzed  triangular 
mass  so  as  to  isolate  and  clamp  its  vascular  attachments  to  the 
posterior  muscles  of  the  neck.  On  the  left  side  lookout  for  the 
thoracic  duct.  At  the  base  of  the  triangle  the  large  number  of  ves- 
sels emerging  from  between  the  posterior  muscles  cause  much  bleeding 
unless  they  are  isolated  and  separately  clamped. 

Excision  of  Vein. — Now  and  then  in  the  axillary  dissection  the  cancer 
is  adherent  to  the  axillary  vein.  There  is  no  objection  whatever  to 
isolate  and  ligate  a  segment  of  this  vein  if  necessary. 

Hemorrhage. — When  the  tumor  is  on  the  sternal  periphery  of  the 
breast  and  for  this  reason  you  are  forced  to  a  dissection  close  to  ribs, 
intercostal  muscles  and  sternum,  you  wall  experience  difi&culty  in 
clamping  and  ligating  the  perforating  intercostal  vessels. 

Should  a  clamp  miss  the  vessel,  do  not  attempt  to  re-clamp  by  push- 
ing the  instrument  into  the  intercostal  muscle,  you  may  perforate  the. 
pleura.  The  hemorrhage  can  be  checked  by  holding  a  bit  of  gauze 
there. 

Recently  in  cases  of  this  kind  I  have  hastened  and  simplified  matters 
by  using  the  electric  cautery  knife.  We  now  know  this  is  a  safer  pro- 
cedure when  near  cancer,  and  if  one  uses  it  slowly  the  vessels  divided 
rarely  require  clamping. 

Shock. — After  a  considerable  comparative  experience  with  nitrous- 
oxide  gas  anaesthesia  and  ether-drop,  I  prefer  ether  in  the  majority  of 
cases  of  complete  operation  for  cancer.  Here  there  is  no  necessity  for 
deep  narcosis.  Shock  is  rarely  observed,  and  if  one  checks  hemorrhage, 
it  should  never  be  fatal. 

Mortality. — -When  the  complete  operation  for  cancer  was  extended 
to  the  complete  supraclavicular  dissection  and  skin-grafting  at  one  sit- 
ting, the  mortality  increased  from  about  ^^  per  cent,  to  3.  Now  that 
this  neck  operation  has  been  given  up  as  a  routine  procedure  and  when 
done  is  always  performed  at  a  second  operation,  the  mortality  has 
fallen  to  less  than  1-2  per  cent. 

Late  Results. — In  a  short  article  of  this  kind  there  is  no  space  to 
consider  this  phase  of  the  subject.  All  our  patients  should  be  carefully 
watched,  because  even  after  complete  operation  for  cancer  there  is  the 
remaining  breast  to  be  looked  after.  Every  one  of  these  patients  should 
be  given  the  proper  information  for  her  own  protection:  "If  you  feel  a 
lump  return  at  once  for  inspection.  No  matter  how  well  3-ou  feel, 
return  for  an  examination  at  certain  given  intervals." 

Function  of  the  Arm. — In  the  first  place  good  function  is  dependent 
upon  healing  without  infection;  second,  upon  early  and  continuous  use. 


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